Head to Toe Assessment

Question 1

Preparation

Answer 1

Gather Correct Supplies, Enter patient’s room & introduce self, Provide Privacy

Question 2

Wash Hands

Answer 2

Assess the hands for breaks in skin. Nails to be short. Remove jewelry unless worn during care. Wet hands, apply soap and wash continuously for at least 20 seconds.

Question 3

Continuation of Preparation

Answer 3

Identify client by using at least two ways; patient name and date of birth.
Check the patient arm band for ID, assist the client into a comfortable position

Question 4

Vital Signs

Answer 4

Pain, Temperature, Pulse, Respiration, O2 Sats and BP

Question 5

Pain

Answer 5

Assess patient for pain: intensity, location, type EG: stabbing, aching, etc.

Question 6

Temperature

Answer 6

Apply protective sheath for oral or if temporal thermometer, remove probe cover.
Properly place probe. Read temp. Discover

Question 7

Manual Peripheral Pulse

Answer 7

Palpate radial puls for full 60 seconds

Question 8

Respirations

Answer 8

Observe or Palpate respiratory rate for 30 seconds.

Question 9

O2 Saturation

Answer 9

put 02 sat on index finger and wait until you get results.

Question 10

BP

Answer 10

Cuff on. finger radial pulse, pump cuff until can’t feel pulse anymore. This is number that it needs to pump too for taking actual BP. Do not use thumb on diameter to hold it in place

Question 11

Document

Answer 11

Write down all vital signs.

Question 12

General Survey

Answer 12

Melissa is Alert & Orientated. Has proper and appropriate speech.

Question 13

Head, Ears, Eyes, Nose, Throat

Answer 13

Inspect: face, pupils = Pupils Equal Round Reactive to Light and Accommodation. External eyes for redness and discharge. Mouth - mucous membranes and condition
Nose - discharge, nasal patency & deviations
Ears- discharge, external canal, lesions and Whisper Test (Purple, 7, Pizza).

Question 14

Thorax & Lung Assessment

Answer 14

Inspect shape, Respiratory Rate, Rhythm, depth, & accessory muscles use or cough, Spinal alignment, Ascultate (6) sounds on posterior and anterior, 2 places in axillary region on each side.

Question 15

Heart & Central Vessels Assessment

Answer 15

Palpate carotid pulse (one at a time), Ascultate A,P, E, T & M.

Question 16

GI & Genitourinary Assessment

Answer 16

Inspect shape of abdomen, Ascultate bowel sounds (4 quads), palpate quads, Assess bowel & urinary habits/probs, last BM.

Question 17

Musculoskeletal, Neurologic & Peripheral Vascular Assessment

Answer 17

Inspect & Palpate extremities (edema, tenderness, temp, & lesions). Cap refill fingers and toes. Inspect Gait/balance.
Strength, Range of Motion in extremities and neck. Locate and Palpate pulses

Question 18

Wrap up

Answer 18

Assist to a comfortable position.
Wash hands
Dismiss self
Document