HEAD to TEO GUIDE

docx

School

Northern Kentucky University *

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Course

610

Subject

Nursing

Date

May 24, 2024

Type

docx

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Uploaded by pbs17

Hi My name is Priyanshi Shah and I am a student nurse practitioner here to perform your comphrensive head to toe examination. May I have the permission to film this video assessment. Here is my ID and I am going to scan the room. I am going to sanitize my hands. Can you tell me your name and age? While walking in patient’s gait is steady and ambulates without any difficulties. Patient vitals: BP, Pulse, SpO2, Temp, Height, Weight Patient is well groomed, well nourished, and looks his stated age. Patient is sitting upright, and his posture is appropriate. The next I am going to inspect the skin. Skin color is evenly disturbed, appropriate for ethnicity. No lumps, bumps, lesions, or redness noted. Skin turgor is normal (pt is well hydrated), Skin is warm to touch. Inspection of the head: head look normocephalic, there is no visible lumps, bumps, or any other trauma or deformities. I am going to palpate let me know if there is any pain or tenderness. (pt denies hair evenly distributed, scalp looks healthy, no lumps, bumps or any open areas palpated). I am going to now palpate TMJ bilaterally (no clicking sound noted bilaterally normal finding) Bilateral ears- symmetrical Bilateral eyes symmetrical Nose is perfect in shape and in midline. No lesions or scars Lips are pink and moist. Eyebrows are aligned symmetrically. Eye lashes evenly distributed. No crusting noted. No other abnormal facial movements noted. Open your mouth: buccal mucosa is pink and moist no bleeding , lacerations, or lesions n oted; teeth aligned appropriately; no missing teeth noted. No cavities noted. Gums pink and healthy. Tongue in the midline. Tonsils +2 bilaterally no signs of inflammation noted. Oropharynx pink and moist no lump, bumps or extra drainage noted. Eyes: sclera is white in color, no redness noted. Look up for me: Conjunctiva is pink and moist bilaterally, Ophthalmoscope: red reflex Look at the optic disc is pink, retinal arteries, and macula- healthy looking. No signs of papilledema or hemorrhaging noted. Otoscope- internal ears ear canal is clear from wax on right and left ear. Tympanic membrane is pearly gray in color and cone of light is at 7 o’clock (left). And 6 o’clock (right) and no redness or inflammation noted Otoscope: Inside of the nostrils. Nasal tissue pink and moist, nasal septum is in midline without any deviation noted. Turbinates are intact. No bleeding noted. Nasal cavity has some hair which is a normal finding. Close one nare and breath in- nares are patent bilaterally. Palpate the sinuses: Maxillary and Frontal

Check for cranial nerve 1-12 CN 1 olfactory nerve: smell CN 2 Optic nerve – visual acuity, confrontation test to check for peripheral vision. CN 3, 4, 6- oculomotor, trochlear, and abducens nerve- 6 cardinal fields of gaze test Also check for pupillary reaction to light and accommodation Checking for direct and consensual eye intact no signs of nystagmus noted. CN 5 trigeminal nerve- close your eye and let me know when you feel the dull and sharp sensation.; for motor function and assess for masseter muscle strength: clench your teeth and can you open your mouth against resistance. CN 7 facial close eyes tightly, raise eye brows, puff cheeks, facial movemebts intact CN 8 Vestibulocochlelar nerve- wispher test, rinne test, weber test CN 9 glossapharyngeal nerve- palpate throat- swallow test. While palpating no masses or abnormalities noted. CN 10- vagus nerve- ahhh uvula stays midline and soft palpate elevates. Can you cough, patient is able to cough CN 11 Accessary nerve shrug your shoulders against resistance, move head against resistance CN 12 hypoglossal nerve open your mouth and move your tongue side to side, and up and down, no abnormalities in the tongue movements. Palpate lymph nodes of head and neck: pain or tenderness. Preauricular Post auricular. Tonsillar Submandibular Submental occipital Anterior cervical chain Posterior cervical chain Deep cervical chain Supraclavicular Infraclavicular Palpate coratid pulses (strong and +2) Auscultate coratid pulses no bruit heard Move your head left and right – NO JVD distention Check for angle of louis- between manubrium and sternum. I am palpating for any heaves, lifts, or thrills. No I am checking for PMI (point of maximal impulse) that is on the midclavicular line on the fifth intercostal space – I can palpate it is strong and +2. No abnormalities noted. Auscultate heart sound- bell and diaphragm. Aortic, pulmonic, tricuspid, and mitral (no abnormal sounds like murmurs, S3, or S4).

Sit upright and take a deep breath – anteriorly his thorax is symmetrical. Posterior is symmetrical no abnormalities noted. No ausculate the lung sounds in all the bronchial and vesicular areas. Lung sounds are clear and no other adventitious sounds heard like wheezes or crackles. Percussing front and back – no dullness noted. Normal finding Check for tractile fremitus – say 99 – no changes in the vibrations bilaterally which is a normal finding. Assess for egophony: say “e” I can hear the same E sound bilaterally both posteriorly and anteriorly. This is a normal finding. Abdominal area- flat and has some hair. No lesions, lumps bumps, or open areas present. Skin is warm to touch. Ausculatate bowel sounds in all four quadrants Musculoskeletal Inspection No signs of atrophy or asymmetry noted.

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