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Head-to-toe assessment flashcards
Every step of the head-to-toe assessment with its technique and normal finding. This is one of NurseLingo's free decks, so every card is here.
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- General SurveyFirst overall impression of the patient
- Level of ConsciousnessLOC: Alertness and orientation baseline
- Assessment OrderInspect, palpate, percuss, auscultate
- Abdomen ExceptionInspect, auscultate, percuss, palpate
- InspectionVisual exam of color, symmetry, lesions
- PalpationUsing touch for texture, tenderness, masses
- PercussionTapping to assess density beneath tissue
- AuscultationListening with stethoscope
- Erb's Point3rd left intercostal space at sternal border
- Aortic Landmark2nd right intercostal space
- Cardiac AuscultationAortic, Pulmonic, Erb's, Tricuspid, Mitral
- PMIPoint of Maximal Impulse: Apical pulse at 5th ICS, midclavicular line
- Vesicular SoundsSoft, low breath sounds over lung periphery
- Bronchial SoundsLoud, high breath sounds over trachea
- Crackles (Rales)Discontinuous popping on inspiration
- WheezesHigh-pitched musical sound, often expiratory
- Pulse Grading0 absent to 4+ bounding (2+ normal)
- Edema Grading1+ trace to 4+ deep (>8 mm, slow rebound)
- Capillary RefillTime for color return after nail-bed blanch
- Skin TurgorElasticity indicating hydration
- Bowel SoundsAuscultated in all four quadrants
- Deep Tendon ReflexesDTRs: Graded 0 to 4+ (2+ normal)
- Romberg TestBalance with feet together, eyes closed
- Auscultating CarotidsListen for bruits over carotid arteries
- Grading Reflexes 0-4Deep tendon reflex scale
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