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 …show more content…
Eyes a. Eyelids: Palpebral Fissure are symmetrical, no ptosis or lid lag. b.Lacrimal Glands: Pale pink, patent, no excessive tearing, dryness, drainage, or edema. c. Eyelashes: Evenly distributed no ectropion no entropion. d.Eyebrows: Even and equally bilateral e. Conjunctiva: clear, pink, moist, without lesions f. Sclera: white & intact g.Cornea: Surface should be moist and shiny and without discharge, cloudiness, opacity, and irregularity. h.Iris: round, symmetrical, and colored: green, blue, brown, hazel, violet, honey, etc. i. Pupils: PERRLA (Pupils are Equal, Round, Reactive to Light and Accommodation) Check pupil reflexes. check twice each eye, direct/consensual, then bring penlight toward nose to assess for accommodation.
5. Ears a. Pinna: Non tender, symmetrical bilaterally, without lesions or masses, (top of pinna should always be equal to outer canthus) - palpate simultaneously b.Tragus: non tender, without lesions c. Mastoid Process (piece of bone inferior posterior ear): non tender, no swelling, equal bilaterally (if