Head to Toe

Question 1

Primary includes (Basic parts)

Answer 1

Airway
Breathing
Circulation
Disability
Exposure
Full Set of Vitals

Question 2

What are the safety checks

Answer 2

• Suction and O2 outlets in wall (presence & function)
• Location of CODE button
• Bed brakes on/bed lowered
• Call bell within patient’s reach

Question 3

Secondary Assessment (Review of systems)

Answer 3

CNS: alert and orientated x 4, PERL (prn), motor and sensory function, pain
CVS: HR, BP, heart sounds, integumentary (wounds), IV access, pulses, edema, CWMS
Resp: RR, O2 sats, O2 therapy, lung sounds, work of breathing, chest tubes, trachea midline
GI: diet, blood glucose, bowel sounds, LBM, abd size/shape/firmness, NGT, ostomy
GU: genitalia, skin breakdown, urine output/colour/quality, Foley catheter, urostomy, nephrostomy tubes, dialysis line, S & S of UTI
Psychosocial: current living situation, referrals for resources (safety equipment, home health etc.) needed, discharge plan, family/friend support, spiritual considerations