Head to Toe Assessment Flashcards
What is the order of systems for head-to-toe assessment?
Introduction
Pain assessment
Vitals
Neuromuscular
Cardiac
Respiratory
GI
GU
Skin
IV
Activity Level Assessment
Fall Risk Assessment
Psychosocial Assessment
Reposition
Exit Routine
Pain assessment
“Are you in any pain?”
“What caused the pain?”
“Does anything make it better or worse?”
“Can you show me where the pain is exactly? Does it radiate anywhere?”
“Can you describe the pain? Sharp? Dull?”
“On a scale of 0-10 with 10 being the worst, how bad is the pain?”
“When did you start feeling this pain?”
“Were you given anything to treat the pain?”
Vitals
Raise the head of the bed
“Have you had anything cold or hot”
-take an oral temperature
Take respiratory rate for 30s, x2
Take radial pulse for 30s, x2
Take BP and O2 sats
Neuromuscular
“Who is the president?”
“Where are you at right now?”
“Do you know what day it is?”
“Why are you at the hospital?”
Arm strength test (push arm against hand)
Leg strength test (push up and down)
PERL -> Pt. stare straight, shine light on pupils
Cardiac
Inspect skin -> pink and warm
Take radial pulse x2
Cap refill test on finger x2
Check hands for edema
Take dorsalis pedis pulse x2
Cap refill test on toe x2
Check the ankle for edema
Listen to apical pulse (left chest)
Respiratory
“Do you have any difficulty breathing? SOB? Cough?”
Listen to lungs (6 front, 6 back)
-full inhale and exhale
GI
Lower head of the bed
Inspect abdomen
Listen to 4 quads of the abdomen
Palpate
- “Any pain or tenderness?”
“When was your last bowel movement? Can you describe it?”
“Any nausea?”
GU
“Are you able to control your bowel movement and bladder?”
“Do you have any difficulty or discomfort urinating?”
“What color is your urine?”
Skin
“Can you turn so I can look at your back?”
Check for bed sores
Have pt. turn back flat
“Do you have any cuts, scrapes, or bruises I can’t see?”
IV
ITRACE -> check from insertion site to machine
- no redness, no swelling, no air in the bag
Check the machine for the right program, right drug, right dose, and expiration date is fine
Activity assessment
“How many people does it take for you to get out of bed?”
Fall risk assessment
“Even though you require no assistance you are a fall risk because of the IV pole due to a chance of tripping”
“I’d have you use the call light if you need to get up and require you to put on nonslip socks and shoes. The bed would be in the lowest position just in case if you do fall it won’t hurt as much”
Psychosocial assessment
“Did anyone visit you today?”
“Do you have a good support system?”
“Who do you live with? Any issues at home?”
“How do you feel about being in the hospital?”
Repositioning
“Here at the hospital, we try to reposition you every two hours to prevent bed sores from developing”
-Turn pt., pillow on back, between elbow and knee
Exit Routine
Develop a plan for treatment/care
Educate patient
Set a goal
Safety check -> bed low, side rails up, call light within reach
“Is there anything I can do for you before I leave?”
Scan pt. and room
Wash hands (20s)
