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8/25/2020 Head to toe assessment - Coggle Diagram
8/25/2020 Head to toe assessment
Initial Steps
Mentally Review, check patient chart, get report, check doctors orders, gather supplies and perform hand hygiene. Knock on door, introduce self to patient.
Radial Pulse
Turning the patient's arm over palm side up. Place two finger tips on the groove of the forearm to check the pulsation of the heartbeat. Assess if it is strong or weak.
Privacy
Explaining what kind of procedure is about to happen to the patient and after getting consent that is when you provide privacy by making sure there is adequate lighting and closing the curtains.
Apical pulse
The apical pulse can be found in the left center of your chest, just below the nipple. Using the stethoscope, listen and count the apical pulse for 30 seconds and multiply by 2 or for 60 seconds if the rhythm is irregular.
Eyes
Assess for jaundice, cloudiness, crusts, or if it is teary.
Initiate Safety Protocol
Making sure the wheels on the bed are locked and adjusting bed to working height.
Lung sounds
Auscultation of breath sounds for both anterior and posterior. Assess for the quality, rate, and rhythm, Check if breathing aides are being used.
DVT
Assess for leg pain, edema, and pitting.
Edema
Is to gently compress the patient's soft tissue with your thumb over the shins and if the spot that was presson on stays indented for seconds whether it be 1+, 2+, it is a sign of swelling in the body caused by excess fluid. Note non pitting if it is normal.
Teeth
Assessing if the patient is wearing any dentures
Leg strength
Tell the patient to bend feet toward its upper surface (doriflex) and then (plantarflex) bending it like a ballerina with resistance.
Oral Mucosa
Assessing if the patient has gingivitis, bleeding in the gums, or if here is anything abnormal on the tongue.
Final steps of assessment
Give the patient an overview of any abnormalities found. Return the bed level back to normal. Tell the patient where the nearest call light is. Put personal belongings of patients within reach. Perform hand hygiene. Document.
Symmetry
Checking for tenderness and lumps on the trachea midline.
bowel function
Asking the patient when was the last bowel sound, consistency, and how often. Also Palpate the abdomen and see if it is soft, firm, distended, and assess for pain. Note: If the patient has a stoma.
Pulse points of the lower body (list all of them and their location)
Carotid artery- neck
Radial artery- On the wrist
Femoral artery- groin area
Popliteal artery-back of the knee
Dorsalis pedis artery- on the foot
Temporal Artery-of the head near the ear
Brachial Artery-behind the elbow
Skin turgor
Pinching the skin on the hand (not too hard) the skin will tent and return back to normal, but if it stays tented up it can indicate dehydration.
urine elimination pattern
Assess if the patient is wearing a catheter. Ask the patient if they feel any discomfort with the catheter.
Asses for elimination pattern.
Note color and if there is any blood in urine.
bowel sounds
Auscultate the bowel sounds starting with the upper left quadrant, upper right quadrant, lower right quadrant, and then lower left quadrant. While using the diaphragm on our stethoscope we are assisting for sounds that are high frequency. It is best to auscultate before palpitations.
Orientation
After verifying the clients identity by having them state their name/last name/DOB while checking wristband, assess if the patient is alert, drowsy, lethargic or confused.
Arm strength
Push resistance between patient and nurse and ask the patient to squeeze pointer and middle finger together for the grip strength and both are to be done bilaterally.
LOC
“Do you know why you’re here?”
“Do you know where you are?”
“Do you know what month it is?”
“Do you know what state we are in?
“Do you know what year it is?
Heart sounds
Listen over the aortic valve area with the diaphragm of the stethoscope. This is located in the second right intercostal space, at the right sternal border. When listening over each of the valve areas with the diaphragm, identify S1 and S2, and note the pitch and intensity of the heart sounds heard.
Capillary refill
Pressing against the nail bed with thumb or pen to see if the blood returns within 3 seconds.
Hair, Scalp, Skin
Assess for any scratches, bald spots, dandruff, abnormal bumps, and lice.
Homan’s sign
Once the knee is extended raise the patient's straight leg to 10 degrees, then passively and abruptly dorsiflexes the foot and squeezes the calf with the other hand. Stop if the patient verbalizes pain.
Nares
Assessing if it is dry, drainage, blood, or cuts.
EOM
Pointing the penlight in the directions below to see if the patients follows.
Perrla
Shines pen light on eyes to see if the pupils constrict when the light hits the pupils and dilates when the light is away. Pupils are equal round reactive to light accommodation.