1. level of consciousness (LOC) : is this person alert? drowsy? lethargic?
2. Head
- Head: check for any abrasions, lice, bumps, etc
- eyes: check for PERRLA (Pupils Equal and Round and Reactive to Light and Accomodation)
- nose
- mouth
check inside the mouth for any mouth sores
3. Neck
- lymph node ( is it swollen?)
- jugular vein distention ( JVD)
4. Arms
- Cap refill ( fingernails; does it refill in 3 secs. or less?)
- hand grip
- radial pulse
- ROM, strength
5. chest
- respiration (shallow?regular?irregular? normal respiratory rate: 12-20 breaths per min)
- skin turgor( does the skin tent up? to assess patient's hydration status)
- apical pulse( left mid clavicular, 5th intercostal space.)
- lung sounds
6. abdomen
- abdominal exam ( bowel sound) : inspect, auscultate, palate.
- BM
- Pain
7. GU
- bladder distention
8. Legs
- pedal pulse (check dorsalis pedis)
- edema
- Homan's sign ( ask patient to dorsiflex their feet while you hold their calf. If sharp pain is present, there's a possible deep vein thrombosis)
- cap refill . ( for the toenails)
- ROM
* Throughout the assessment process, inspect the skin.
