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Physical assessment is an inevitable procedure not just for nurses but also for doctors. Establishing a good assessment would later-on provide a more accurate diagnosis, planning, and better interventions and evaluation, that’s why it’s important to have a good and strong assessment. Below is your ultimate guide in performing a head-to-toe physical assessment. You might want to print a copy and bring it during your hospital duty, making your physical assessment better and more accurate! Skull, Scalp & Hair
Normal Findings: Skull
Scalp
Hair
Face
CN V (Trigeminal)1. Sensory Function
2. Motor function
CN VII (Facial)1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
2. Motor function
Normal Findings
Eyebrows, Eyes, and Eyelashes
Normal findings Eyebrows
Eyes
Eyelashes
Eyelids and Lacrimal Apparatus
Normal Findings Eyelids
Lacrimal Apparatus
Conjunctivae
In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:
Normal Findings
Sclerae
Normal Findings
Cornea
Normal findings
Anterior Chamber and Iris
Normal Findings
Pupils
Normal Findings
Cranial Nerve II (optic nerve)
Peripheral vision or visual fields
Follow the steps on conducting the test:
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
Follow the given steps:
Ears
Normal Findings
Nose and Paranasal Sinuses
Paranasal Sinuses
Normal Findings
Cranial Nerve I (Olfactory Nerve)
Mouth and Oropharynx LipsInspected for:
Normal Findings:
Temporomandibular
Normal Findings:
GumsInspected for:
Normal Findings:
TeethInspected for:
Normal Findings
TonguePalpated for: Normal Findings:
UvulaInspected for:
Normal Findings:
TonsilsInspected for:
Neck
Normal Findings:
Normal Findings:
Normal Findings:
Anterior approach:
Normal Findings:
Thorax (Cardiovascular System)Inspection of the Heart
Normal Findings:
Palpation of the Heart
Normal Findings:
Percussion of the Heart
Auscultation of the Heart
Positioning the client for auscultation:
Auscultating the heart:
Normal Findings:
BreastInspection of the Breast
Normal Findings:
Palpation of the Breast
Normal Findings:
Abdomen
Inspection of the abdomen
Normal Findings:
Auscultation of the Abdomen
Peristaltic sounds
Percussion of the abdomen
Percussion of the liver
Renal Percussion
Palpation of the AbdomenLight palpation
Normal Findings:
Deep Palpation
Liver palpation
Normal Findings:
ExtremitiesInspection
Palpation
Normal Findings
See Also |