7/28/2019 Head to Toe Note Card

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Wash hands, introduction, Orientation X3, VS; Gloves: 1)eyes-

position, alignment, lids, conjunctiva, cornea, sclera, lacrimal

apparatus, lashes, maybe PERRLA, 2)mouth-pharynx, soft

palate, tongue movement, swallowing, teeth, mucosa; 3)scalp,

head symmetry; Eyes:PERRLA if not done above (verbalize

dim light) 6 cardinal fields of vision, peripheral vision, Snellen

chart, EARS: Inspect, Whisper test; NOSE: Inspect (can do

above); NECK: ROM, Vein distention, Muscle strength, Lymph

nodes (name areas as palpate); CV: apical pulse, Auscultate w/

bell & diaphragm; RESP: Rhythm, rate, Palpate-

7/28/2019 Head to Toe Note Card

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anterior/posterior thorax & spine, Auscultate-

anterior/posterior/lateral lung sounds; ABDOMEN: Inspect,

listen, palpate, Ask about urine; BREAST: Palpate models,

Teach self breast exam; UPPER EXTREMITIES: Palpate-

temp, moisture, turgor, edema, also joints, Skin-color, lesions,

ROM, Sensation-hot, cold, soft, hard, Strength, Muscle tone,

Cap refill, Radial pulses, Vibration, Coordination; LOWER

EXTREMETIES: Same as upper except popliteal and pedal

pulses, Patellar reflex, Babinski, ROMBERG

GAIT-observe as go to Snellen chart