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08/25/2020 head-to-toe assessment - Coggle Diagram
08/25/2020 head-to-toe assessment
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.
Lung sounds
Auscultation of breath sounds both anterior and posterior; assess quality, rate, and rhythm. Take note for use of any breathing aides. Note ratio and pattern of breathing; thoracic inspection.
Edema
To check for edema that is not obvious, you can gently press your thumb over the foot, ankle or leg with slow, steady pressure.
Hair, scalp, skin
Assess the condition on the patients scalp, checking for cut bruises or head lice.
Skin turgor
To check for skin turgor, the health care provider grasps the skin between two fingers so that it is tented up. Commonly on the lower arm or abdomen is checked. The skin is held for a few seconds then released. Skin with normal turgor snaps rapidly back to its normal position.
Nares
Assess the nose area for dryness or excess liquid
Pulse points of the lower body
Assess popliteal & pedal posterior tibial pulses
Orientation
The assessment involves asking the patient to repeat his own full name, his present location, and today's date.
Arm strength
Test flexion and extension at the elbow by having the patient push and pull against your hand.
Test extension at the wrist by asking the patient to make a fist and resist your pulling it down.
Teeth
Assess the teeth area, making sure of presence of dental care
Homan’s sign
the patient’s knee is in an extended position and the examiner forcefully dorsiflexes the patient’s ankle. A positive sign is indicated when pain in the popliteal region and the calf is elicited as the foot is dorsiflexed.
PERRLA
When you assess for consensual response make sure you are looking at both eyes. Shine the penlight in one eye and look at that eye, then you look at the other eye and shine the penlight in the eye you were just looking at while looking at the other eye. Repeat this with the other eye.
Bowel function
Ask the client when was the last time they had a bowel movement. Ask if they noticed a different smell, if it looked different and if it was soft, firm, or hard
Privacy
Provide the patient privacy by closing the door or curtain
Radial pulses
Simply lay your index and third fingers on the inside of your wrist below the base of your thumb, between the bone and the tendon. This spot is over the radial artery. When you feel the thump of your pulse, count the beats for 30 seconds then times by 2
Initial steps
Identify the client by asking for the clients armband if they have one, their first and last name, and date of birth
Knock on the clients door and Identify yourself to the client
Perform hand hygiene
Collect equipment and supplies
Check the doctors orders
Mentally review the procedure
Apical pulse
Place the diaphragm or bell of the stethoscope over the apex of the heart located at the fifth intercostal space left of the mid clavicular line. 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.
Symmetry
To assess facial symmetry, the nurse must first stand in front of the patient, looking at the clients face. The nurse would then ask the patient if they could smile, make a sad face, laugh all checking if the client can respond
Leg strength
Ask the patient to push against your hand or pull toward them
Oral Mucosa
Assess the mouth area, checking for no cuts or lumps in the mouth
DVT
Check if the client has any redness, swelling or pain in the legs, check to see if the legs are very warm
EOM
Patient follows the pen in front of his face with his eyes, the nurse goes in the direction of cat whiskers
Urine elimination pattern
Ask the client when was the last time they urinated. Ask if it was painful, if there was a smell and the color
Eyes
Assess the condition of the eyes
Bowel sounds
If no assessment finding of bowel sounds, you need to listen over the quadrant for at least five minutes. If you hear something, you can move to the next quadrant. You should also do your auscultation before palpation and percussion to avoid influencing bowel sounds.
Initiate safety protocol
Check to make sure the bed wheels are locked, the handrails are raised and the bed is at a proper working height
Capillary refill
It can be measured by holding a hand higher than heart-level and pressing the soft pad of a finger or fingernail until it turns white, then taking note of the time needed for the color to return once pressure is released. Normal capillary refill time is usually less than 3 seconds.
LOC
To accurately determine LOC, use objective criteria, such as eye opening, motor response, and verbalization, both spontaneously and on command.
Final steps of assessment
Restore the Unit. Collect the Used Equipment; Dispose of, Clean, or Store Items in the Proper Places. Lower the bed to the lowest position and have the side rails up.
Document and Report the Procedure
Remove Gloves and Other Protective Equipment. Perform hand hygiene
Vital signs
Pulse
Blood pressure
Restorations
Pain level assessment
Temperature