Head to Toe Assessment

Question 1

Personal/Patient Safety

Answer 1

demonstrate hand hygiene, appropriate glove use/changing, patient identification

Question 2

AIDET

Answer 2

acknowledge, introduction, duration, explanation, thank you

Question 3

Safe Exit/Fall Precautions

Answer 3

bed in lowest position, bed brakes on, side rails are correct, tray table in correct position, personal itens within reach, call light within reach, floor free of clutter

Question 4

OLD CARTS

Answer 4

onset, location, duration, characterisitcs, aggravating factors related symptoms, treatment, and severity

Question 5

Head

Answer 5

inspect head/face features for symmetry and expression; palpate head; palpate temporomandibular joint

Question 6

Hair

Answer 6

inspect hair (texture, condition, distribution, color of hair, scalp lesions, and infestations)

Question 7

Eyes

Answer 7

inspect external eye structures (eyebrows, eyelids, lashes, conjunctiva, sclera, and cornea); assess visual acuity (snellen chart or rosenbaum); Assess PERRLA

Question 8

PERRLA

Answer 8

pupils are round, reactive to light and accomodate

Question 9

Ears

Answer 9

inspect auricle, tragus and lobules; inspect outer/middle ear for cerumen buildup; palpate auricle and mastoid process

Question 10

Nose

Answer 10

inspect external nose; inspect internal nares for patency, polyps, intact septum, and color of mucosa; palpate sinuses (frontal and maxillary)

Question 11

Throat/Mouth

Answer 11

inspect lips, teeth, gums and buccal mucosa; inspect uvula (ahhh), tonsils, soft/hard palates and posterior pharyngeal wall; assess strength of tongue movement;

Question 12

Neck

Answer 12

inspect neck, trachea, and thyroid; palpate trachea and thyroid for swelling, masses and deviated trachea

Question 13

Lymphatic

Answer 13

palpate lymph nodes for swelling and tenderness; pre/post auricular, occipital, submental, submandibular, tonsillar, cervical, and supraclavicular vodes

Question 14

SKin

Answer 14

inspect for general color, lesions, rashes, scars, moisture, tattos, piercing; palpate skin for texture, temperature, moisture, turgor and thickness

Question 15

Nails

Answer 15

inspect the nails for shape, contour and color; palpate nails for thickness and firmness

Question 16

Heart

Answer 16

inspect anterior chest wall for contour and retractions; ausculate apical pulse for rate and rhythm; auscultate the heart in 4 locations for abnormal sounds, pitch or splitting (aortic, pulmonic, tricuspid, mitral)

Question 17

Lungs and Respiratory

Answer 17

inspect patient for posture, appearance, breathing effort, anterior/posterior thorax for shape, symmetry, muscle development, and coastal angle; auscultate anterior breath sounds (8 positions), lateral breath sounds (4 on right, 3 on left), posterior breath sounds (10 positions)