Head to Toe Assessment Flashcards
Preparation
Gather Supplies
Introduce Yourself
Privacy
Wash Hands
Look for cuts Hands lower than elbows 1" above wrist At least 20 seconds Pat dry from fingers up
Continuation of Preparation
Ask for name and birthdate
Check arm band
Explain head to toe assessment
Assist to comfortable position
Vital Signs-Pain
Intensity
Location
Type
Vital Signs- Temperature
Apply protective sheath
Place probe under tongue
Read temp
Discard cover
Vitals-Peripheral Pulse
Identify and palmate the radial pulse for 60 seconds
Vitals-Respiration
Observe respirations for 30 seconds minimum
Vitals-Oxygen Saturation
Check for fingernail polish
Place probe on index finger
Ask patient to hold still
Document immediately
Vitals-BP
Palpate radial pulse
Pump up till you can’t feel it
Deflate and take BP
Document immediately
General Survey-
Appearance and Mental Status
Ask person who they are
Ask person where they are
Ask person the time or date
State that patient is oriented to person, place,and time.
State that patient has appropriate speech and has good posture and hygiene
HEENT
Head, Ears, Eyes, Nose, Throat
Inspect face for movement and sensation Pupil size Inspect for discharge and redness Inspect mouth-mucous membranes Inspect nose for discharge Inspect ears
State that patient has no abnormal movements or sensations, pupils are equal, round, reactive to light, and accommodation. Mucous membranes are moist, nose is free of discharge, and ears are free of wax. Z
Thorax and Lung Assessment
Rate, Rhythm, Depth, Accessory Muscle Use, Cough
Inspect Spinal Alignment
Auscultate breath sounds on anterior and posterior in at least 6 places
State that patient has normal respiratory rate, rhythm, depth, no accessory muscle use, and no cough. No scoliosis. Normal breath sounds with no wheezing, crackles, etc.
Heart and Central Vessels
Palpate carotid arteries
Auscultate heart sounds in aortic, pulmonic, erbs, tricuspid, mitral.
State strong S1 and S2 sound with no murmur or extra S3 or S4 sounds.
Gastrointestinal and Genitourinary Assessment
Inspect shape of abdomen
Auscultate bowel sounds in all 4 quadrants.
Lightly palpate all 4 abdominal quadrants for distinction or tenderness.
Ask last bowel movement and every problems
Ask about urinary problems
Musculoskeletal, Neurological, and Peripheral Vascular Assessment
Inspect and palpate extremities for edema, temperature, tenderness, and lesions.
State no edema, normal temperature, no tenderness or lesions.
Check muscles and extremities, for size and symmetry
State that extremities are symmetrical.
Check capillary refill of fingers toes. State that it is normal.
Inspect Gait and Balance
Range of motion in neck, arms, and legs.
Assess strength.
Locate and palpate pulses: radial, brachial, posterior tibial, and dorsalis pedis.
