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1. Before you start, -proper intro to pt
what do you do? -hand hygiene
-asked appropriate health history related to pt (OLDCART)
2. Vital signs BP, temp, HR, apical pulse, RR
3. Gen survey: -facial expressions
describe -orientation
appearance of pt -posture
-speech/hearing
-hygiene
-pt activity
-assesses hydration
4. Gen survey: -color
describes
assessment of -last bowel movement/urination
skin
5. gen survey: bow-
el/bladder/nutrition as- - describe it
sessme -normal diet (changes)
nt -changes in weight (up or down)
6. PA: head and face - palpates facial bone, TMJ, sinuses
-head/neck ROM and muscle strength
-cranial nerve test (VII - facial nerve [looks for symmetric facial
features- smile, putt cheeks])
7. PA: eyes - inspects external features, sclera, conjunctiva, iris
-assesses pupillary response and accommodation
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