Head to Toe assessment Flashcards
transfer of accountability (TOA)
- at end of each shift nurses report information about their assigned patients to the nurses working on the next shift
- can be orally in person, an audiotape recording, a summary report sheet, or at the patient’s bedside
- needs to be current, objective and concise
what should you assess prior to entering the pt’s room?
isolation precautions, allergies, fall precautions, other relevant info.
what does general survey consist of?
appearance, body structure, mobility and behaviour
what should you check following your brief introduction to the patient?w
IV lines and solutions, flow rates for IV solutions, if pt has Foley catheter. wound drains (note drainage, colour, amount), if pt has oxygen running and if concentration is correct, any monitors you need to assess
what should you notice in the pt’s environment?
bedrails, bed positioning, access to call bell, cues related to pt’s support system, if pt has phone or TV
what measurements are usually taken in general survey?
vital signs and specialized measurements (e.g. abdominal girth) if indicated
completing a pain assessment
depending on pt’s clinical condition and context, choose an appropriate tool and ask about pain at rest vs. activity as well as response to any pain meds; rate from 1 to 10
what systems are assessed in head to toe?
neurological respiratory, cardiovascular, skin, abdomen, genitourinary, activity
neurological
eye opening, verbal response, pupillary reflexes, motor response, note ptosis or facial droop, evaluate sensation in hands/legs if indicated and ability to swallow
respiratory
assess FiO2 (amt O2 administered via mask or nasal prongs), assess skin integrity around device, SOB on rest or exertion, auscultate breath sounds and lung lobes, comparison of air entry for both sides, ask pt to cough and deep breathe (sputum? colour? consistency?), encourage use of incentive spirometer if present
incentive spirometer
device that expands lungs by helping you to breathe more deeply and fully
cardiovascular
compare apical to radial pulse, is there a pulse deficit (signals weak ventricular contraction), assess heard sounds, check capillary refill, pretibial edema (palpate posterior tibial end and pedal pulses - compare sides for pulse presence and equality)
skin
colour, temp., turgor, lesions or wounds, dressings and any drainage, is pt at risk for skin breakdown? Braden scale (pressure sore risk), functioning air mattress (if pt has one)
nursing actions to prevent skin breakdown
avoid pressure, turn at minimum of every 2 hours, avoid shear, pay attention to nutrition and hydration, keep skin clean and dry
alternating pressure mattress
important to prevent and manage pressure injury for pts who cannot be repositioned frequently, incl. those treated for intensive care traction, respiratory, pain, end of life care
assessing the site of the IV
redness, edema or drainage? also check IV site at beginning of examination after checking solution and flow rate
abdomen
assess contour, listen to bowel sounds, inquire about last bowel movement, ask about nausea, pain or vomiting, passing gas and constipation, assess diet, colostomy or ileostomy, drainage tubes or incisions?
Inspect, auscultate, percussion, palpation
colostomy
creates an opening from the colon to the outside of the body through the abdominal wall (opening is called stoma)
ileostomy
creates an opening from the ileum to the outside of the body through the abdominal wall (opening is called stoma)
genitourinary
voiding pattern, indwelling catheter, check colout and amount of urine if pt has drainage bag, bladder scan if little urine output, assess 24 hr fluid balance (hydration, dehydration, kidney function and perfusion)
activity
this is checked before meeting with the patient; is the pt on bedrest? (then bed should be 15º or higher) if pt is ambulatory then follow guidelines for assisting pt to sitting position, ambulation and transfer
what should be done upon completing the head to toe assessment?
note exam findings that necessitate immediate attention and document the initial assessment as soon as possible
What does the head to toe assessment focus largely on?
noticing
During the head to toe assessment what data is gathered?
both subjective and objective data simultaneously
Musculoskeletal
how much assistance is needed?
is the gait steady and symmetrical?
does the patient have a cane or walker?
Could the patient benefit from a referral to physiotherapy or occupational therapy?
Report or not: altered level of consciousness and confusion
report
Report or not: systolic less than 90 or greater than 160
report
Report or not: temp greater than 38?
report
report or not: HR less than 60 or greater than 100 bmp
report
report or not: respiratory rate is less than 10 or greater than 28 per min?
report
report or not: oxygen saturation is above 92%?
no; normal is between 92-100; anything below 92 is worrysome
report or not: urine output is less than 30mL /hour for 2 hours?
report
report or not: dark coloured urine or bloody urine
report; exception for urology patients
report or not: vomiting after surgery and not relieving with medication
report
report or not: surgical pain and not controlled with medication?
report
report or not: bleeding?
report
report or not: restlessness or anxiety
report
