Head to Toe SIM Flashcards
What are the first steps when entering a patients room prior to a focused and head to toe assessment?
Airway
Breathing
Circulation
LOC
Height/Weight
Vital signs
What is assessing the overall state?
Healthy Emancipated Disheveled Emotional state Skin Color
What is the order for assessing a patient
Inspect
Palpate
Ausculatate
Assessing abdomen
Inspect
Auscultate
Percussion
Palpate
What is assessed for respiratory?
Rate
Rhythm
Symmetry
Effort
Where are the breath sounds found?
6 Anterior
6 Posterior
2 on each side laterally
Where are the heart sounds?
APE To Man Aortic 2nd ICS Pulmonic 2nd ICS Erb's point 3rd ICS Tricuspid 4th ICS Mitral/Apical 5th ICS
What do you look for in a focused abdomen assessment?
Look listen feel
Listen for up to 5 minutes if no bowel sounds heard
Hyperactive vs Hypoactive bowel sounds
Palpate each quadrant starting int he RLQ moving clockwise
Upper/ Lower extremeties
Pulses
Cap refill
Grips/pushes/pulls
Overall skin
Color
Temperature
Moisture
Turgor
Edema
Pitting
Non-pitting
Absent
Pedal pulses
Strength and symmetry
What do you assess after the head to toe?
Any lines/equipment
Wounds, dressings, foley, pumps, NG tube, SCDs
