Head-to-toe Flashcards
What is the difference between a rapid assessment and a routine head to toe?
Rapid assessment: requires 1 minute or less to complete. At beginning of each shift. Used as an initial assessment to prioritize actions and interventions. Provides a baseline
Routine head to toe: Early in the shift. used to father more in-depth data about a patient for whom care will be provided
How does a rapid assessment influence the continued assessment of the patient?
- Helpful in reducing anxiety because priorities can be established alone or in collaborative discussion with the faculty, preceptor, or staff
- Establishes a baseline for ongoing patient interaction and care
How does the routine head to toe assessment influence your continued assessment of the patient?
Data gathered in the initial assessment will guide the direction of care and inform the nurse about the need for, as well as the type of frequency of, continuing assessment
What is assessed in a rapid assessment? (10)
- introduction
- LOC
- distress signs
- skin colour
- respiratory effort
- posture, facial expression and symmetry
- response to introduction
- speech for clarity
- temperature
- visible equipment
What is assessed in a routine/initial head-to-toe assessment?
- introduction
- general appearance
- measurement (vitals)
- Respiratory system
- cardiovascular system
- Abdomen
- genitourinary
- skin
- activity
Describe the head to toe assessment
- early in your shift, but you will be doing ongoing assessments of your hospitalized patient as you care for, and interact with them.
- includes collaboration with the patient and their family, and is essential in the development of your plan of care.
- will become more focused and in-depth if you discover anything of concern.
- is an essential component of your complete integrative health assessment.
Describe a rapid assessment
- can be completed in one minute or less completed at the beginning of each shift
- allows you to quickly assess your patient and prioritize your actions and interventions.
- provides a baseline for ongoing nursing care.
what is the ultimate goal of all nursing practice?
the optimization of health
What is included in the introduction of the head to toe assessment?
- hand hygiene
- identify yourself and length of time you will be providing care
- identify patient with 2 patient identifiers
- note position and location of patient
- call bell within reach
What is included in general appearance of head-to-toe assessment?
- appears stated age
- LOC
- skin colour
- nutritional status
- posture and position (comfort, pain)
- physical deformities
- mobility
- facial expression
- mood and affect
- speech
- hearing
- personal hygiene
What is included in measurement of head-to-toe assessment?
- temperature
- pulses (radial and dorsalis pedis)
- respiration
- blood pressure
- pulse oximetry (O2 sat)
- pain (0-10), note location and quality
What is included in respiratory system of head-to-toe assessment? (5)
- respiratory effort
- oxygen therapy
- auscultate breath sounds (pos and ant)
- positioning if needed
- assess for coughing, if productive, assess sputum
What is included in the cardiovascular system of the head-to-toe assessment? (3)
- auscultate apical pulse
- assess heart sounds in APETM
- assess capillary refill, edema, and pulses
What is included for abdomen of the head-to-toe assessment? (5)
- Inspect for contour, skin colour, and pulsations
- Auscultate bowel sounds
- Palpate and percuss
- time of the most recent bowel elimination and/or flatus
- Assess drains, tubes, dressings, when indicated
What is included in the genitourinary part of the head-to-toe assessment? (2)
- Assess urine output – voiding – frequency and amount, or catheter drainage amount
- Assess the color, clarity, and odour of urine
