HEAD TO TOE Flashcards
ENTRANCE TO ROOM
perform hand hygiene, gathered my materials. KNOCK. Hi I am emily, i will be your nursing student today. provide for privacy. Can i have your name and date of birth please? Hand hygeine.
environmental survey
I am performing my environmental survey. the bed rails are up, the bed is in a low and locked position, the floors are clear, personal items are within reach, the bed alarm is not set due to no fall risk, the room is well lit and the room is safe/
general survey
I am performing my general survey. the patient has even and ulabored respirations, skin color is appropriate for ethnicity, alert and oriented, well nourished, symmetrical, relaxed posture, laying in bed, well kept, dressed appropriately, clear speech. Can you take a couple steps for me? ROM intact, steady gait
ASSESS LOC
Do you know where we are right now? do you know todays date? why are you here today?
okay I am here to do a head to toe assessment on you. This just means I am going to take a quick look at everything from your head to your toes. does that sound okay?
are you in any pain right now?
there is nothing attached to my patient at the moment.
Neuro assessment
shine light in pupils, PERRLA. Pt obeys commands, eyes open spontaneously, clear speech and answers questions.
Respiratory assessment
expose torso. listen to breath sounds side to size, anterior and lateral,
breath sounds equal, clear, and unlabored. AP to transverse diameter is 1:2 . chest is symmetrical, skin is clear or lesions
skin turgor present and prompt.
cough strong and unproductive
demonstrate incentive spirometry
cardiac
count intercostal spaces
mid clavicular line
listen for 60 seconds
s1,s2 present, heart rate 88 beats per minute
abdominal
expose from iliac crest to ribs. abdomen non-distended, skin color appropriate for ethnicity, no redness or lesions.
how often do you have bowel movements? when was your last? what color? consistency? any diet intolerances?
how many times a day to you urinate? do you walk there yourself? would you describe the amount as small medium or large? what color is it?
ausciltate bowel sounds beginning in RLQ. Bowel sounds normoactive and present in all four quadrants.
palpate. no tenderness in any quadrants, no palpable masses.
skin torso
inspect back, coccyx, elbows, heels. Color consistent throughout, no redness, skin intact. palpate back, coccyx, elbows, heels. no lumps, masses, pain, or tenderness
assess for temperature. skin is warm and dry.
no calf edema, pain, or warmth.
upper extremeties
upper extremeties are symmetrical, even in color and hair distribution, free of lesions and edema. texture is smooth and consistent. VISUALIZE ELBOWS.
upper extremeties are warm and dry throughout.
pulses 2+ bilaterally. hand grip strength 5+ bilaterally. capillary refill less that two seconds. Nails are evenly shaped, pale in color, and flat
lower extremities
skin tone is even with no redness, even hair distribution, no edema or lesions visible. lower extremeties are smooth, non tender, no lesions present. Lower extremeties are warm and dry throughout.
calfs are symmetrical. No pretibial edema. grade 0.
plantar and doral flexion are symmetrical, grade 5 bilaterally.
dorsalis pedis pulses present, 2+ bilaterally. toenails are pale, even in shape, flat contour. capillary refill is less than two seconds.
end of assessmentt
I will be back to check on you, your room is still clean, bed is low and locked, room well lit. WASH HANDS> DOCUMENT
