Appearance: Inspect Pt’s overall appearance.
■ Hygiene, state of well-being, nutrition status.
■ Level of consciousness, emotional status, speech patterns, affect, posture, gait, coordination, and balance.
■ Any gross deformities.
Skin: Inspect and palpate exposed skin.
■ Warmth, moisture, color, texture, lesions.
■ Scars, body piercings, tattoos.
Hair and Nails: Inspect hair, hands, and nails.
■ Hair color, fullness, and distribution, noting any signs of malnutrition (thinning).
■ Infestation or disease.
■ Clubbing of nails, deformity, abnormalities of hands.
Head: Inspect and palpate face and scalp.
■ Facial symmetry.
■ Scalp tenderness, lesions, or masses.
Eyes: Inspect sclera, conjunctiva, and pupils.
■ Color and hydration of conjunctiva and sclera.
■ PERRLA: Pupils equal, round, reactive to light and accommodation.
Ears: Inspect.
■ Hearing impairment.
■ Use of hearing aids.
■ Pain, inflammation, and drainage.
Nose: Inspect.
■ Congestion, drainage, and sense of smell.
■ Patency/equality of nostrils, nasal flaring.
■ Septal deviation.
Throat and Mouth: Inspect teeth, gums, tongue, mucous membranes, and oropharynx.
■ Color and hydration of mucous membranes.
■ Gingival bleeding or inflammation.
■ Condition of teeth (any missing, severe decay), dentures.
■ Difficult or painful swallowing.
■ Presence or absence of tonsils.
■ Oral hygiene and the presence of odor.
Neck: Inspect and palpate neck. Test ROM.
■ Jugular vein distention (JVD), tracheal alignment (deviation), and retractions.
■ Swollen lymph nodes or enlarged thyroid.........
■ Decreased ROM, stiffness, or pain.
7/7/14
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