Head To Toe

Front 1

General Survey
1)Intro
2)Dress
3)Hygiene

Back 1

1)Hi Ms.___, I'm ___, a student nurse at RCON. What do you prefer I call you?
2)Client is appropriately dressed for the season, clothes are well fitting and neately groomed.
3)Client appears clean and there is no odor detected.

Front 2

Skin
1)Face/Neck-4 characteristics
2)Anterior Trunk/Abd-4 C
3)Posterior Trunk-4 C
4)Arms-4 C
5)Legs-4 C
6)Moisture of skinfolds

Back 2

1-5)State color, texture, lesions w/measurements, and temperature bilaterally
6)Moist or dry from R to L in antecubital and popliteal areas.

Front 3

Nails (1 SIDE ONLY)
1)Fingernails-4 C & 4 T
2)Toenails-4 C & 4 T

Back 3

1-2)Inspect and describe grooming(cleaned and manicured), color and markings(pink tones w/ no longitudinal ridging), consistency(hard, immobile). Assess nail angle(160 degrees), skin mobility/turgor(quickly returns to normal), edema(grade 0), and capillary refill(less than 2 seconds).

Front 4

Head and Neck
1)Hair-3 C
2)Scalp-3 C
3)Lymph Nodes-11 locations

Back 4

1)Describe amount(thick), distribution(evenly distributed), texture(hair is fine and somewhat elastic).
2)Describe color(pale peach) and palpate for tenderness (no tenderness or lesions).
3)Palpate preauricular, post-auricular, occipital, tonsilar, submandibular, submental, superficial cervical, posterior cervical, deep cervical, supraclavicular, infraclavicular (All should be nonpalpable and nontender bilaterally).

Front 5

Head and Neck
1)Face-2 C & 4 T

Back 5

1)Describe palpebral fissures and nasolabial folds, skin color and lesions. Test facial movement (frown, wrinkle forehead, puff out cheeks), symmetrical from R to L-TESTS CN VII (Facial). Test sensation(sharp/dull & light touch), client identifies 100% correctly-TESTS CN V(trigeminal). Test temporal masseter muscle strength, client should clench jaw equally from R to L-TESTS CN V(trigeminal). Test temporomandibular joint(client opens mouth and slides jaw), should be symmetric with no crepitus noted-TESTS CN V(trigeminal)