Clinical Gead To Toe Flashcards
1
Q
IWIN
A
- Introduce self
- Wash hands, provide privacy
- Identify pt
- Explain head to toe
- Allergies
- Pain scale
2
Q
Vitals
A
- Temperature (oral)
- Pulse (pulse oximeter)
- Respirations
- Blood pressure
- SpO2
3
Q
Neuromuscular
A
- A&O
“He/She is alert & oriented x…” - Behavior/Affect
“He/she is calm and cooperative” - Speech
“His/her speech is ______” - U & L Extremity Strength:
boxer style; try to push & pull on arms
grip strength
legs flexed; push & pull
“He/she has equal strength of the U & L extremities bilaterally”
4
Q
Cardiovascular
A
- Heart tones
- Apical Rhythm
- Radial & dorsalis pedis pulses
“The radial & dorsalis pedis pulses are 2+ bilaterally” - Peripheral edema
Feel with palms & backs of hands
“I do not note any edema of the …” - Capillary refill of hands
“Capillary refill is brisk bilaterally”
5
Q
Respiratory
A
- Pattern
“He/she has a regular breathing pattern, I don’t not the use of accessory muscles” - Breath Sounds
“Breath sounds are present & clear in all fields”
6
Q
Gastrointestinal
A
- Inspect abdomen
“Abdomen is round. I do/don’t note any striae, pulsations, or surgical scars. The umbilicus is midline & inverted/everted” - Auscultate
Start at the RLQ at the ileocecal valve
“Bowel sounds are present in all 4 quadrants” - Palpate
Light & deep, ask if it’s painful at all
“The abdomen is soft, no tender to light & deep palpation and I felt no masses” - Last Bowel Movement
- Do you know when you need to go
7
Q
Geintourinary
A
- Urine output by: voiding, foley
- Do you know when you need to urinate?
- What color is your urine?
- Do you notice any odor or cloudiness?
8
Q
Integumentary
A
- Color
- Temperature
- Moisture
- Skin Turgor
- Integrity
“Skin is warm, dry, & intact. Skin color is normal for ethnicity”
9
Q
Musculoskeletal
A
- U & L Extremity ROM
“She/He has full ROM of U & L extremities” - Gait (if able)
“Even & smooth” - Assistive Device
Walker, wheelchair, none
