In: Nursing
You completed your full head-to-toe assessment skills demonstration last week and now will document your results. Continue to document only the objective findings for this section without bias or explanation. Remember if you can’t feel something then it is “nonpalpable,” if you can’t hear something just state they were not heard such as no bowel sounds heard (unless you listened for the full five minutes which we wouldn’t want to do for our purposes – then you could document absent bowel sounds). Be descriptive if necessary but at the same time be brief.
Head to toe examination-
1) General appearance- well oriented with time , place and
person . Body position normal.
2) Head and neck a) - eyes- no regurgitation on pressure , pupil
reacting,
b) mouth , denture and facial symmetry- intact , normal
3) chest - a) inspection- normal expansion and retraction , no
accessory muscle use , no jugular venous pulsation Seen .
b) auscultation- apical heart rate heard .
normal breath sounds . No added adventitious sound.
c) palpation- normal symmetrical lung expansion
d) percussion- normal
4) Abdomen - a) Inspection- normal not distended , no venous
prominence seen.
b) auscultation- bowel sounds asculated normally
c) palpation- liver palpated just below the right pleural space
. Spleen not palpable . Bladder distended .
d) percussion- no fluid thrill present .
5) extremities- arms and legs - no Edema or bruises .
palpate- pulse- normal in rhythm , rate and volume , no
radioradial delay or radiofemoral delay.
6) mobility- gait normal