NR509 Head to Toe Assessment 100% Correct

NR509 Head to Toe Assessment 100% Correct Introduce yourself & patient Hi, my name is ________ and I will be performing a physical examination for NR509 Advanced Physical Assessment at Chamberlain University My name is _____ and I give permission for this video assessment to be uploaded to Chamberlain college of nursing Facial skin No discoloration or lesions Head Midline, symmetrical, normal in size Lymph node palpation (9 locations) Preauricular - in front of ear Post auricular - behind ear Occipital - back of head Move forward - tonsillar Under jawline - submandibular, Submental Anterior cervical Posterior cervical Supraclavicular - above clavicles ---Do not feel any enlargement, equal bilaterally CN 5 Trigeminal nerve Motor component - palpate over the master muscle as patient clenches jaw --No distortions, great strength Sensory component -- close eyes, let me know where you feel my touch -- forehead, cheeks, chin, nose CN 7 Facial nerve Inspect for facial symmetry with... -Smile -Frown -Raise eyebrows -Puff cheeks -Pucker lips ----symmetrical bilaterally Outer Ear: Inspection Inspect outer ear for nodules, skin lesions & symmetry Ear: Inspection (Otoscope) Pull ear up & back Auditory canal -- clear, no redness, swelling, drainage, or cerumen Tympanic membrane -- pearly gray, no effusion in middle ear Do same for other ear -- no redness, swelling, drainage, or cerumen, tympanic membrane is pearly gray, no fluid in external auditory canal Ear: Palpation Palpate pinnae and tragus for nodules & tenderness CN 8 Acoustic nerve (hearing) Whisper test - whisper words out of patient's sight & patient repeats words back. Test one ear at a time. "one, two, three" and "four, five, six" --Hearing intact bilaterally Eyes: Inspection Conjunctiva -- pink, clear, no drainage or lesions Sclera - white & clear CN 2 Optic nerve Central vision *Snellen pocket eye chart 6 ft away, cover one eye...read lowest line possible...repeat other eye --- 20/20 left eye, right eye, both eyes Peripheral vision Stand up at eye level, look straight ahead, do not move head. --Hands forward from back --Hands down from above --Hands come from below Check pupillary response to light (PERRL) --Ophthalmoscope light --Stare at nose --Come from side....pupil constricts...check other eye ----Pupils 2-3mm, respond to light equally Extraocular muscles CN3, 4, 6: 3 - Oculomotor, 4 - Trochlear, 6 - Abducens Check extra ocular muscles of eye --H or star pattern --Follow finger with eyes only --extraocular muscles are intact equally Nose: Inspection Inspect nose --Midline & straight --No obstruction --No notable fracture --No swelling Assess nasal turbinates and septum (using light source) --Insert speculum of otoscope into nose --Tip nose up with thumb --Look inside left turbinates --pink, moist, septum midline, no swelling .......Angle anteriorly --Septum straight, no deviation ........Cover right side --Straight septum --Turbinates pink, moist, no swelling .....Angle anteriorly --Septum straight, no deviation Nose: Palpation Palpate frontal & maxillary sinuses Throat & Mouth: Inspection Inspect... -Lips -- pink & moist -Teeth -- no decay or cracks -Gums -- no redness or swelling -Buccal mucosa -- pink & moist -Palate (hard & soft) -- intact, pink & moist -Tongue -- smooth, pink & moist -Floor of mouth (under tongue) -- no nodules or drainage; pink & moist -Posterior pharynx - pink, no postnasal drainage -Tonsils (grade tonsils if present) CN 9 & 10 Glossopharyngeal, Vagus CN 9 - glossopharyngeal - gag reflex not tested CN 10 - Vagus nerve - Say "Ahhh" - soft palate & uvula rise symmetrically with phonation CN 12 Hypoglossal Stick out tongue, move it left to right TMJ Open & close mouth --No crepitus, clicking, or tenderness Neck: Inspection Inspect for obvious deformities & symmetry --Symmetrical, no obvious deformities Neck: Palpation Palpates trachea - midline, no abnormalities Palpates thyroid gland --Find the cricoid process --One hand in the suprasternal notch --Put fingers on each side, retract one side --Ask to swallow --Feel thyroid rise, no nodules Palpate carotid artery pulsation, one at time --Normal, bounding Neck: Auscultation Auscultate over the carotid for bruits with bell --Hold breath --No bruit Neck: ROM Flexion -- chin to chest Extension -- look to ceiling Lateral flexion -- ear to shoulder Rotation -- left to right ---All intact equally CN 11 Spinal accessory nerve Shrug shoulders against resistance --Equal & intact Heart: Ausculation Bell & Diaphragm; Verbalize areas: Aortic valve - 2nd intercostal space, right sternal border Pulmonic valve - 2nd intercostal space, left sternal border Erb's point - 3rd intercostal space, left sternal border Tricuspid - 4th intercostal space, left sternal border Mitral - 5th intercostal space, midclavicular line Anterior chest: Inspection & Auscultation Inspect for obvious deformities & symmetry Auscultate lungs in anterior lung fields --Intercostal spaces 6 spaces Posterior chest (Back): Auscultation Auscultate posterior lung fields: Start above scapula, move side-to-side in intercostal spaces, 8 spaces Go down into bases of lungs Assess lateral lung fields (get right middle lobe) Upper extremities: Hand Inspection Inspect joints of hands: --No redness, swelling, or deformities Upper extremities: Palpation Palpate for capillary refill (Left & Right) --Press a fingernail & release; returns healthy pink <3 seconds Radial pulses --Equal, 2+ bilaterally Hand grips (bilateral) --Grip my hands tight -- 5/5 strength Passive unilateral ROM of elbows (flexion/extension) Strength of biceps/triceps (bilateral) - flex/extend elbow against resistance - 5/5 strength Passive unilateral ROM of shoulders (flexion, extension, internal rotation, external rotation, abduction, adduction) Upper extremities: Cerebellar coordination Serial finger opposites Hand flip-flops --Well coordinated DTRs Unilateral DTRs Biceps Patellar Achilles Abdomen: Inspection Contours & symmetry No distortions Abdomen: Auscultation Bowel sounds - present, normoative all 4 quadrants Bruits - with bell Aortic - right below xiphoid process, midline L renal - above & lateral to L of umbilicus R renal - above & right to umbilicus Iliac - L below umbilicus & R below umbilicus ---No bruits heard Abdomen: Percussion Percuss all 4 quadrants: Tympany Dullness Flatness ---All areas normal & tympanic Abdomen: Palpation Palpate all 4 quadrants for tenderness & masses --No masses noted Palpate liver & spleen (verbalize) Liver - upper right quad, note if you feel edge of liver Spleen - upper left quad...come laterally - note if you feel edge of spleen Perform Blumberg's sign (verbalize) - hand vertically 90 deg - press down into abdomen...rebound tenderness = +blumberg - peritonitis Lower extremities: Inspection Inspect skin integrity of lower extremities --No lesions or edema ROM of hips Passive unilateral ROM of hips Flexion Abduction Adduction Internal Rotation External rotation **hip extension not tested for this exam ROM of knees Passive unilateral ROM of the knees Flexion Extension Knee strength Strength at the knees (bilateral) Flex/extend against resistance - 5/5 strength ROM of ankles Passive unilateral ROM of ankles Dorsiflexion Plantar flexion Rotation Ankle strength Bilateral Dorsi/plantar flex against resistance - 5/5 strength Pedal pulse Assess dorsalis pedal pulse --2+ & equal bilaterally Spine: Inspection & Palpation Patient standing Inspect & palpate Expected curvatures Alignment Tenderness Spine: ROM ROM of spine Flexion - bend over, touch toes Extension - straighten up, extend backwards Lateral flexion - one side, then other Rotation - right & left --good, active ROM Romberg Arms at sides Close eyes for 20 secs Looking for swaying --No swaying = negative Romberg Gait Just several steps forward and then back --Steady & even gait This concludes my physical exam