Compete Heath Assessment - (Gude Head to Toe)

Genera Appearance:
- LOC (aert/ethargc/non-responsve?)
- Skn coor (pae/pnk/.)
- Orentaton (to person, pace, and tme)
- Nutrton status, posture, mood, persona hygene
- Neuroogca test, f necessary
Skn: (Start w/assessng cents hands) - on skn ook for rashes, esons, dryness,
har oss
- nspect na beds, capary ref (brsk/suggsh, >3 sec.)
- Temperature to touch (coo/cod/warm/hot)
- Texture (dry/daphoretc)
Move on to: checkng Hands (Neuro/MS)
- Cench fst (facng up/supnate), turn hands over (pronate), extend fngers,
ponts fngers up, down, nward, outward, touch the thumb and each of the
fngers together
- Papate each |ont n the wrst and hands
- Check Rada Puse.then take a hand and ask to make a fst, papate rada
and unar artery.have them reease fst and you reease the unar
artery(checkng capary ref).REPEAT but reease the rada artery
- Stabze ebow and have them push aganst your hand (baanced on wrst)
- Papate ebow
- Bracha puse
Head and Face:
- Inspect and papate scap, har, cranum
- Inspect face for expresson, symmetry
- Papate tempora artery
- Papate temporomandbuar |ont as person opens and coses mouth
- Papate maxary snuses and fronta snuses
- Have person sme, frown, bow cheeks
- Cose Eyes - Cotton Swpe Test
Eye: (ask f change n vson, pan)
- Test extraocuar musces: cornea ght refex, sx cardna postons of gaze
- Inspect externa eye structures
- Inspect con|unctvae, scerae, corneas, rdes
- Test pup: sze, response to ght and accommodaton
- Test vsua feds - wgge fngers nto vew (upper, mdde, and ower
perspectve)
- *usng an opthamoscope: nspect ocuar fundus: red refex, dsc, vesses, and
retna background
Ear: (ask f pan, hearng oss, vertgo, rngng, dscharge, nfectons) - pu up, back,
and sghty out
- Inspect the externa ear: poston and agnment, skn condton, and audtory
meatus
- Move aurce and push tragus for tenderness
- *Wth otoscope, nspect the cana, then the tympanc membrane for coor,
poston, andmarks, and ntegrty
- Test hearng: voce test, tunng fork tests (Weber and Rnne)
Nose: (ask f any cods, congeston, nosebeeds)
- Inspect externa nose: symmetry, esons, and faca symmetry
- Test patency of each nostr
- *Wth specuum, nspect the nares: nasa mucosa, septum, and tubrnates
Mouth and Throat: (check for condton of teeth/gums, ast denta vst, sore throat)
- *Wth penght, nspect the mouth: bucca mucosa, teeth and gums, tongue,
foor of mouth, paate, and uvua
- Grade tonss, f present
- Note mobty of uvua as person phonates "ahhh" and test gag refex
- Ask person to stck out tongue
Neck: (check for umps, stffness, goter)
- Inspect neck: symmetry, umps, and pusatons
- Papate the cervca ymph nodes
- Inspect and papate the carotd puse, one sde at a tme
- Papate the trachea n mdne
- Test ROM and musce strength aganst your resstance: Head Forward, Head
Back, Head Turned Sde to Sde, and Shouder Shrug
Chest (Posteror and Latera)
- Inspect the posteror chest: confguraton of the thoracc cage, skn
characterstcs, and symmetry of shouders and musces
- Fremtus "99" - set up 4 spots
- Percuss over a ung feds
- Auscutate breath sounds; note any adventtous sounds
Chest (Anteror)
- Inspect: respratons and skn characterstcs
- Auscutate breath sounds
(SUPINE)
Breasts: ook for umps, pan, and dscharge
Heart:
Use Be gong down, Then Daphragm back up
X Md Axary Lne
Abdomen:
- Auscutate bowe sounds
Lower Extremtes:
- nspect symmetry, skn characterstcs, and har dstrbuton
- Test ROM:
Hps - Have patent bend each knee to chest
Support eg at 90deg. at anke and knee and rotate at hp
Support at anke and hp bone then abduct
Knees - papate poptea meday; mk poptea then tap meday
Fex eg aganst tabe and papate poptea
Ankes - nspect top of anke (rub)
Inspect (rub up and down) Aches
Fex, extend foot wth support
Grp hee and fex (bend) toes
Feet - Separate toes and nspect
- Papate puses: poptea (fex eg), posteror tba (beow anke bone), dorsas
peds
- Papate for temperature and edema (ether top of foot, shns - press for 5
sec.)
- Sharp/Du Test
- Grab both egs and rase to 45deg. For approx. 30 sec.; then have them st up
and vew capary ref of egs
SIT UP:
- Push eg (strength) aganst you
- Pu eg (strength) versus you
- Have person run each hee down opposte shn (cerebra)
- Refex test - Babnsks refex
Standng:
- Have them take a few steps away, turn, and come back
- Then wak toe-to-toe away.wak hee-to-hee back
- Ask them to hod on the edge of somethng for support (f need be) and stand
on one eg, swtch
- Standng behnd have them bend over, Papate ength of spnous process
- Stabze ther pevs, and have them bend rght-eft (ateray), hyperextend,
and rotate