Head to Toe assessment

Question 1

transfer of accountability (TOA)

Answer 1

• 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

Question 2

what should you assess prior to entering the pt’s room?

Answer 2

isolation precautions, allergies, fall precautions, other relevant info.

Question 3

what does general survey consist of?

Answer 3

appearance, body structure, mobility and behaviour

Question 4

what should you check following your brief introduction to the patient?w

Answer 4

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

Question 5

what should you notice in the pt’s environment?

Answer 5

bedrails, bed positioning, access to call bell, cues related to pt’s support system, if pt has phone or TV

Question 6

what measurements are usually taken in general survey?

Answer 6

vital signs and specialized measurements (e.g. abdominal girth) if indicated

Question 7

completing a pain assessment

Answer 7

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

Question 8

what systems are assessed in head to toe?

Answer 8

neurological respiratory, cardiovascular, skin, abdomen, genitourinary, activity

Question 9

neurological

Answer 9

eye opening, verbal response, pupillary reflexes, motor response, note ptosis or facial droop, evaluate sensation in hands/legs if indicated and ability to swallow

Question 10

respiratory

Answer 10

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

Question 11

incentive spirometer

Answer 11

device that expands lungs by helping you to breathe more deeply and fully

Question 12

cardiovascular

Answer 12

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)

Question 13

skin

Answer 13

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)

Question 14

nursing actions to prevent skin breakdown

Answer 14

avoid pressure, turn at minimum of every 2 hours, avoid shear, pay attention to nutrition and hydration, keep skin clean and dry

Question 15

alternating pressure mattress

Answer 15

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

Question 16

assessing the site of the IV

Answer 16

redness, edema or drainage? also check IV site at beginning of examination after checking solution and flow rate

Question 17

abdomen

Answer 17

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

Question 18

colostomy

Answer 18

creates an opening from the colon to the outside of the body through the abdominal wall (opening is called stoma)

Question 19

ileostomy

Answer 19

creates an opening from the ileum to the outside of the body through the abdominal wall (opening is called stoma)

Question 20

genitourinary

Answer 20

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)

Question 21

activity

Answer 21

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

Question 22

what should be done upon completing the head to toe assessment?

Answer 22

note exam findings that necessitate immediate attention and document the initial assessment as soon as possible

Question 23

What does the head to toe assessment focus largely on?

Answer 23

noticing

Question 24

During the head to toe assessment what data is gathered?

Answer 24

both subjective and objective data simultaneously

Question 25

Musculoskeletal

Answer 25

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?

Question 26

Report or not: altered level of consciousness and confusion

Answer 26

report

Question 27

Report or not: systolic less than 90 or greater than 160

Answer 27

report

Question 28

Report or not: temp greater than 38?

Answer 28

report

Question 29

report or not: HR less than 60 or greater than 100 bmp

Answer 29

report

Question 30

report or not: respiratory rate is less than 10 or greater than 28 per min?

Answer 30

report

Question 31

report or not: oxygen saturation is above 92%?

Answer 31

no; normal is between 92-100; anything below 92 is worrysome

Question 32

report or not: urine output is less than 30mL /hour for 2 hours?

Answer 32

report

Question 33

report or not: dark coloured urine or bloody urine

Answer 33

report; exception for urology patients

Question 34

report or not: vomiting after surgery and not relieving with medication

Answer 34

report

Question 35

report or not: surgical pain and not controlled with medication?

Answer 35

report

Question 36

report or not: bleeding?

Answer 36

report

Question 37

report or not: restlessness or anxiety

Answer 37

report