Check Off List

Question 1

Hello my name is Nadira Mohamed and I will be doing head to toe assessment. Before I enter the patients room I will confirm the following data:

Answer 1

1. Verify physician order, patient name and date of birth, height , weight , race and gender.
2. I have a pen, penlight, stethoscope,blood pressure cuff and tongue depressor
3. Normal vital signs : b/p 120/80 , R 12-20, Pulse 60-100, pulse OX 94-100%. Tempt 96.6-99.3

Edema scale :O+: None (0 mm)
1+: Trace (2 mm)
2+: Mild (4 mm)
3+: Moderate (6 mm)
 4+: Severe (8mm+)

Pitting vs non-pitting

Non pitting- water balloon; rebounds back to original place
Pitting – sand balloon; stays depressed

Pulse Scales
0-3 scale
0+: Absent
1+: Thready/Weak 
2+: Normal
3+: Bounding

0 -4 scale

0+: Absent
 1+: Thready 
2+: Weak
3+: Normal 
4+: Bounding

PQRST pain scale 
P =provokes
Q =quality 
R=radiates
S=severity
T=time

Question 2

Knock On the door

Answer 2

Hello I am Nadira and I am going to be your nurse today. Can you verify your name and date of birth please?
Thank You.
I am going to be perform a head to toe exam as ordered by your doctor.

Question 3

Wash hands, provide privacy, raise bed to working

height

Answer 3

Wash hands, provide privacy, raise bed to working

height

Question 4

Are you feeling any pain?

Answer 4

patient is not feeling any pain. If pain was present

1. I would assess pain using PQRST pain scale
2. medicate, return in 30 minutes and reassess

Question 5

Step 1: Neurological Assessment

Answer 5

I will asses for level of consciouness ( LOC)
Can you tell me your full name?
where your at?
what time it is?
why are you here?
 Patient is alert, orientated to person, place, time, and situation. 
Speech is normal
mood and affect are approperiate 


Question 6

Step 2. Head

Answer 6

Assessing head for symmetry, rashes and

lesions

Question 7

Step 3. Ears

Answer 7

assess for drainage, cerumen, and any
issues hearing (hearing aids)

Question 8

Step 4. Eyes

Answer 8

assessing the pupil and iris color for any drainage,
redness.
Do you wear glasses, contacts or have any issues seeing?
i. PERRLA= pupils Equal Round Reactive to Light and Accommodation

Question 9

Step 5. Nose

Answer 9

assessing for patency, deviated septum,

drainage, are pink moist and intact

Question 10

Step 6. Throat

Answer 10

Assessing for redness, swelling, uvula
midline
Do you have any issues swallowing ?
Check gag reflex

Question 11

Step 7. Mouth

Answer 11

lips are pink moist and intact.

Do you have dentures? any issues with eating? The tongue is pink moist and no thrush

Question 12

Step 8. Neck

Answer 12

Assessing for coordinated head movement,
No masses tenderness or breakdown
Trachea is midline

Question 13

Step 9. Skin

Answer 13

Assessing the skin for lesions, rashes, breakdown,
bruising, color, temperature and moisture,
turgor
Assessing the nails for shape and color, and capillary refill <3 seconds

Question 14

Step 10. Heart sounds

Answer 14

assessing all pulses the temporal, facial, carotid, apical, brachial, radial, ulnar, femoral, popliteal, postural tibial, dorsal pedis.

Aortic 2nd intercostal space right sternal border

Pulmonic 2nd intercostal space left sternal border

Erb’s point 3rd intercostal space left sternal border

Tricuspid 4th intercostal space left sternal border

Mitral 5th intercostal space left mid-clavicular line and I will listen to the apical pulse for one full minute.

Question 15

Step 11. Respiratory

Answer 15

Inspect, auscultate, palpate (Look, listen &
feel)
b. Inspect the chest for any lesions, masses,
incisions, or artificial openings such as central
lines, pacemakers or scars
c. Inspect under the breasts for rashes or yeast
d. Auscultate lung sounds (8 on front, 6 on back
and 2 on each side)
e. Does the patient use of oxygen or other devices
or have a productive or non-productive cough?

Question 16

Step 12. Gastrointestinal

Answer 16

Inspect, Auscultate, Palpate, Percuss
i. Inspect for masses, tenderness, lesions
or any artificial openings such as G
tube, colostomy, incisions
i. Inspect size and shape of abdomen
ii. Auscultate for bowel sounds (starting in the LLQ)
1. Listen for a five minutes if you do not hear any bowel sounds and then confirm with another nurse
iii. Palpate for any masses, tenderness

b. What are their normal bowel habits?
c. Does the patient have any issues swallowing
d. Normal bowel sounds 5-35 per minute




Question 17

Step 13.Genitourinary

Answer 17

a. Inspect for any masses, bruising, rashes, or
skin breakdown
b. Palpate for any masses or tenderness
c. Urine output and description
d. Assess for altered elimination

Question 18

Step 14. Musculoskeletal

Answer 18

a. Perform range of motion on the upper and
lower extremities
i. Passive versus active
b. Examine strength in upper and lower extremities: strong and equal on both side
c. Use of assistive devices

Question 19

Step 15.Clean up supplies and discard gloves appropriately

Answer 19

Clean up supplies and discard gloves appropriately

Question 20

Step 16 Return patient to lowest position, side rails up (if

ordered)

Answer 20

Return patient to lowest position, side rails up (if

ordered)

Question 21

Step 17. Wash hands

Answer 21

Wash hands

Question 22

Step 18 Document findings in the chart/electronic health

record

Answer 22

Document findings in the chart/electronic health

record

Question 23

Step: 19. Teach patient to

Answer 23

Call for fever, pain or chills

Question 24

Step 20: Pray that you pass this assessment the first time!!!!

Answer 24

Prayer is the best medicine .