Head to Toe Flashcards
What is before introducing yourself?
hand hygeine
PERRLA means
pupils equally round, reactive to light and accomodating
What is after PERRLA
cardinal fields of gaze
What equipment do you gather in advance?
Stethoscope, BP cuff, pulse oximeter, penlite, thermometer, gloves.
What is before hand hygeine?
gather equipment
What is after gather equipment?
hand hygeine
What is after introducing yourself?
identify the patient
Physical move 1:
Aim a light at the side of their head, have them look at you, check pupils. Then pull back and make their eyes follow the light side to side
After you look at eyess, what next?
Light up their nose. Look at the septum, turbinates.
After you look up their nose, then what? What’s involved?
Light up their ears. Touch tragus.
What is before nose lighting?
Eye lighting.
What is before ear lighting?
Nose lighting.
What is after ear lighting?
Finger snapping.
What is before finger snapping?
Ear lighting.
What is before identify the patient?
introduce yourself
What is after fingersnapping?
Mouth lighting
What is before mouth lighting?
finger snapping
What do you do while mouth lighting?
Say AHHH. Stick out your tongue, move tongue left and right. Clench your teeth.
What is after mouth lighting?
Face touching. Forehead and cheek. Say :”Can you feel that? That? Shrug your shoulders.
What is after identifying patient?
verify allergies
What’s before face touching?
Mouth lighting
What is after face touching?
Neck touching
What is before neck touching?
Face touching
What do you do when neck touching?
Make a W with your fingers to see if trachea is aligned. Get behind them. Put hands over thyroid, say “swallow.”
What do you assess for carotids?
feel pulse, listen for bruit
What is before verifying allergies?
identify patient
What is after verifying allergies?
assure privacy
Where is the aortic pulse?
2nd R intercostal
Where is pulmonic pulse?
2nd L intercostal
Where is tricuspid pulse?
4th L intercostal at sternal border
Where is apical pulse?
5th L intercostal space
Where is Erb’s point?
3rd L intercostal space
Where is mitral pulse?
5th intercostal
What is after neck touching?
Whipping out the stethoscope, palpate carotids and use bell to listen. Touch apical pulse for 1 minute, note if irregular, say take a deep breath and touch 4 lung lobe points on front, 6 on back.
What’s before whipping it out?
Neck touching.
What’s after whipping it out?
“Lie down and pull up your shirt.” say “I am inspecting your abdomen.” Listen to 4 quadrants. Palpate 4 places lightly and 4 places deeply.
What’s before Lie down?
Whipping it out.
What’s after lie die?
hands
What’s before feet?
hands
What’s after hands?
feet
What’s involved in face touching?
Forehead and cheek. Say :”Can you feel that? That? Shrug your shoulders.
What is involved in whipping it out?
palpate carotids and use bell to listen. take apical pulse for 60 sec, note if irregular, say take a deep breath and touch 4 lung lobe points on front, 6 on back.
What is involved in lie down etc?
“I am inspecting your abdomen.” Listen to 4 quadrants. Palpate 4 places lightly and 4 places deeply. ASK appetite, N/V, last diarrhea/constipation, have you urinated today, any burning, unusual odor or other problems
How do you do feet?
Check temp and color. Touch both pulses, tent skin. Push with your feet. Pull. Check capillary refill. Check sensation.
What is before assure privacy?
verify allergies
What is after verify allergies?
ensure privacy
what do you explain about what is about to occur
checking heart, breathing, overall condition head to toe, it won’t hurt, you’ll stay dressed, at the end we will know more about your health
what do you do before explain
ensure privacy
What do you do after explain?
say, do you have any questions?
What do you do before asking if they have questions?
explain the procedure
What do you do after asking if they have any questions?
raise bed to working height
What do you do before raising the bed to working height?
ask if they have any questions.
What do you do after raising the bed to a comfortable working height?
don gloves if needed, if not, assess LOC and orientation
How do you assess level of consciousness and orientation?
Date and time, place, what are you here for today.
What do you do before assessing LOC and orientation?
raise bed to comfortable working height
What do you do after assessing LOC and orientation?
count heart rate and respiration
how do you count heart rate and respiration?
get pulse for 1 minute, get resp for 30 sec and multiply by 2
What do you do before heart rate and respiration?
assess LOC and orientation
What do you do after heart rate and respiration?
blood pressure
What do you do before blood pressure?
heart rate and respiration
how do you do B/P?
put on cuff, pump up to 30 above normal systolic, ease off pressure, listen for the first beat and the last beat
What is after B/P?
O2 sat and temp
What is before O2 sat and temp?
B/P
What is after O2 sat and temp?
pain
How do you assess pain?
intensity, duration, location, character aggravating, mitigating
What is before pain?
O2 sat and temp
What is after pain?
Head and neck- eyes first
What does Lake Land have as a single item on head and neck that Lakeview lacks?
swallow assess
What is after swallowing?
Whip it out.
What is before squeeze my fingers?
abdomen
What is after squeeze my finger?
hand temp and color
What is before hand temp and color
squeeze my fingers
What is after hand temp and color
radial pulse
What is before radial pulsse?
temp and color
What is after raidal pulse?
cap refill
What is before cap refill
radial pulse
What is after cap refill
sensation
What is before sensation
cap refill
What is after foot sensation
homan’s sign, plantar push
What is after plantar push
check IV
What is before plantar push
Homan’s sign
What is before Homan’s sign?
Foot sensation
What do you check for IV?
solution, rate, site
What do you check before IV?
plantar push
What do you check after IV?
O2 settying and type
What do you check after O2 setting and type?
catheter
What do you check before catheter
O2 setting and type
What do you check after catheter?
room saftey
what doi you check before room safety
catheter
What do you check after room safety
4 ps
What are the 4 p’s?
pain, potty, possessions, position
What is before 4 p’s?
room safety
What is after 4 p’s?
hand hygeine
What is before closing hand hygeine?
4p’s
What is after hand hygeine and remove equipment?
document
Document what?
B/P, resp, HR, O2 sat, pain, temp, orientation, hand and foot strength level, whether equal bilaterally, IV rate and site, unusual findings, PERRLA, HEENT WNL, cap refill
what is after assure privacy?
EXPLAIN
What is after head and neck?
swallow
What is after abdomen/ lie down
hands
What do you ask during abdominal assessment?
ASK appetite, N/V, last diarrhea/constipation, have you urinated today, any burning, unusual odor or other problems
