1. Head to Toe Assessment https://www.youtube.com/watch?v=cP4zgb9H3Cg
Generalized patient assessment
Work from the head down
Know normal = identify abnormal

2. Palpate Head and Neck
Checking for lumps and bumps any lesions or tenderness

3. Check the ears
Use an Otoscope

4. Check Nose and Mouth
Is there redness, swelling, drainage, abnormal bumps, color, lesions

5. Pupil Check PERRLA (pupils, equal, round, react to light, accommodate)
Accommodate – ability of eyes to focus on objects that are close up and faraway

7. Neck Veins

8. Heart Sounds

9. Auscultation of Breath Sounds
Normal
Crackles- light crackling, bubbling
Rhonchi- coarse crackles
Wheezes- creaking, whistling, high pitched

10. Pulse Checks Strength of pulse 0 = absent 1 = barely palpable
2 = easily palpable
3 = full
4 = Bounding pulse

11. Capillary Refill < 3 second Blood return
The rate at which blood refills empty capillaries
Indication of dehydration and peripheral perfusion

12. Reflexes

13. Reflexes

14. Reflexes

15. Homan’s Sign

16. Skin Turgor 1-3 second return
Used to assess the degree of fluid loss or dehydration

17. Skin Breakdown Check

18. Peripheral Edema Caused by fluid in the tissues tends to be dependent
0 no edema
+1 Trace indentation rapid return to normal
+2 Mild indentation rebounds in a few seconds
+3 Moderate, second to return to normal
+4 Severe, >30 second to return to normal

19. Peripheral Edema

20. Bowel Sounds Absent, Hyperactive, Hypoactive, Normal
To state absent you must listen for 5 min in each quadrant

21. Palpate the abdomen
To be done after listening to bowel sounds

22. Pain Location, duration, sensation, intensity
What makes it worse or better

24. Baby Reflexes

25. Assessment Song