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4 Cards in this Set
- Front
- Back
What are the steps for the head to toe assessment?
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1. Interpret vital signs including O2 Saturation if needed.
2. Perform Pain/Subjective data assessment. 3. Perform neurological mental status. Orientation X3 4. Perform pulmonary assessment. 4-6 anterior, 8-10 posterior, 1 lateral. 5. Perform cardiac assessment. Auscultate apical pulse noting S1, S2, rhythm, murmur. 6. Perform abdominal assessment. Inspect. Auscultate each quadrant, palpate. 7. Upper extremities: Assess radial pulses for rate, rhythm, strength, and symmetry. Temp, color, cap refill 8. Lower extremities: Assess pedal pulses, edema, temp, color, strength 9. Skin |
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Focused Pain Assessment
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Observe for behavioral cues: facial expressions, movement, etc.
P: Provokes/Relieves Q: Quality R: Radiates S: Severity T: Timing/Duration U: Understanding (Patient's) |
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Focused Head & Neck
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1. Inspect face for symmetry, shape, appearance.
2. Inspect/palpate cranium for m/l/t, symmetry - UNIVERSAL PCS. 3. Inspect/palpate lymph nodes. Pre/post auricular, occipital, Submadibular, sublingual, submental, Ant/Post cervical chain, supraclavicular. 4. Inspect/palpate position of trachea 5. Inspect/palpate thyroid. |
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Focused Eye
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1. Inspect for symmetry
2. Inspect external structures (conjunctiva, sclera) UNIVERSAL PCS 3. Direct/Consensual pupillary light reflex and corneal light reflex. 4. Inspect for convergence, accomodation. 5. 6 cardinal fields of gaze 6. Red reflex with opthalmoscope. |