1. General Survey
! Level ! Awake & Alert
a. Orientation to person, place, time b. Ability to Communicate in full sentences with clear speech c. Posture: upright and erect, shoulders level and symmetrical d. Personal Hygiene: Clean & neat, no odor, dresses appropriately for the weather. 2. Integumentary System:
a. Color: Uniform color - pink, tan, brown, olive. Slightly darker on exposed areas.There are normally no areas of bleeding, ecchymosis, or increased vascularity. No skin lesions should be present except for freckles, birthmarks, or moles, which may be flat or elevated. b. Temperature: Warm and dry bilaterally. Hands and feet may be slightly cooler than the rest of the body. Skin surfaces should be non tender. (use back of both hands on patient’s forearms) c. Textures: Skin should feel soft/fine or coarse/thick. d. Turgor: When the skin is released, it should instantly recoil, no tenting. Best place to assess: Ant. Chest or abdomen. **Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing. 3. Head, Face, Neck
a. Cranium: The head should be normocephalic, midline, and symmetrical. b. Scalp: The scalp should be white to light brown, shiny, intact, and without lesions or masses, flaking, or pidiculi (lice) c. Hair: Pale blonde to black, thick or thin, curly or straight, coarse or fine, shiny or dull. d. Frontal Maxillary Sinuses: Should be non palpable and non tender (must ask “did that hurt?”) e. Cervical Lymph Nodes: Should be non palpable and non tender, non visible or inflamed. (Preauricular, postauricular, occipital, submental, submandibular, tonsillar, anterior cervical chain, posterior cervical chain, supraclavicular. e. Best place to assess: Ant. Chest or abdomen.
**Verbalize: I will integrate the integumentary system throughout the rest of the exam through checking and observing.
Physical Assessment Lab 120-103