Head-To-Toe Assessment (R. Abdomen)
In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles....
Category: Fundamentals of Nursing
Head-To-Toe Assessment (Q. Breast)
Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position. The client is seated...
Head-To-Toe Assessment P. Thorax (Cardiovascular System)
Inspection of the Heart The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts Normal Findings: Pulsation of the...
Head-To-Toe Assessment (O. Neck)
The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension. Normal Findings: The neck is straight. No visible mass or lumps....
Head-To-Toe Assessment N. Cranial Nerve I (olfactory Nerve)
To test the adequacy of function of the olfactory nerve: The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. (e.g. coffee)....
Head-To-Toe Assessment (M. Nose and Paranasal Sinuses)
The external portion of the nose is inspected for the following: 1. Placement and symmetry. 2. Patency of nares (done by occluding nosetril one at a time, and noting for...
Head-To-Toe Assessment (L. Ears)
1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the...
Head-To-Toe Assessment K. Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or the six cardinal position of gaze. Follow the given steps: 1. ...
Head-To-Toe Assessment J. Cranial Nerve II (optic nerve)
The optic nerve is assessed by testing for visual acuity and peripheral vision. Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the...
Head-To-Toe Assessment (I. Pupils)
Examination of the pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is...
