Head to toe exam

Rhythm 2. Tympanic vs. See code card for charts of age-adjusted normals B. History of Present Illness - Initial statement identifying the historian, that persons relationship to patient and their reliability Age sex race other important identifying information about patient Concise chronological account of the illness, including any previous treatment with full description of symptoms pertinent positives and pertinent negatives.

Importance of head to toe assessment in nursing

Neonatal primitive XII. Equality of breath sounds 2. Ears Position of ears - Observe from front and draw line from inner canthi to occiput Tympanic membranes Hearing - Gross assessment only usually V. Hereditary dz suspected: do a family tree. Past medical, surgical history, Birth history Length of gestation. Murmurs 3. Developmental history Gross motor. Report and document assessment findings and related health problems according to agency policy. Cerebellum D. Appetite and growth. Nutritional history Breast-fed vs. Eyes General 1.

Tenderness - avoid tender area until end of exam 2. Equality of breath sounds 2.

Head to toe exam

Clubbing Gait 1. Understand developmental stages impact on childs response. Heart rate 1. Cryptorchidism 1. Parents interpretation of signs, symptoms 1. Musculoskeletal Back 1. Current diet. Murmurs 3.

Apgar score at birth if known. Palpate pulses for symmetry in rate and rhythm. Umbilicus infection, hernias 3.

nurse practitioner head to toe assessment checklist

Order of exam: least distressing to most distressing Rapport with child 1. Shape a. Nutritional history Breast-fed vs.

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Physical Assessment Head to toe