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HEAD TO TOE ASSESSMENT - Coggle Diagram
HEAD TO TOE ASSESSMENT
FINAL STEPS OF ASSESSMENT
Throughout the entire Head-To-Toe assess skin for color, temperature, wounds, scars, dryness, rashes, redness, bruises, marks, etc. If dressing present note condition of incision or wound and dressing date, condition
Note and document any findings, note iv fluid, wounds and dressing, if patient is using oxygen, cpap machine, feeding tube, note skin turgor, if patient have catheter (note the amount of urine or color in the bag, note output)
Restore the unit”, lower bed to lowest level, tell patient where call light is, put
belongings the patient needs within reach of the patient, etc.
Perform hand hygiene.
INITIAL STEPS
Handwashing - Prevent the Spread of microorganism, infection control
The General Survey - Check Doctor's Order, Identifying the correct patient
Introduce self to client - Establishing Rapport
Explain actions and procedures to the patient - To identify patient cooperation and willingness
Maintain patient privacy and provide adequate lighting to perform exam - To maintain safety
Initiate safety protocol necessary (wheels locked, raise bed to working height). - To obtain and maintain proper Body Mechanics and avoid injury to self
ORIENTATION
The patient’s attention span is assessed first; an inattentive patient cannot cooperate fully and hinders testing. Any hint of cognitive decline requires examination of mental status
Determine if the person is "awake, alert, and oriented, times three (to person, place, and time)."
LOC
=> Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment
Assess for alertness, if patient is drowsy, lethargic, confused, obtunded
A mildly depressed level of consciousness or alertness may be classed as lethargy; someone in this state can be aroused with little difficulty. People who are obtunded have a more depressed level of consciousness and cannot be fully aroused. Those who are not able to be aroused from a sleep-like state are said to be stuporous. Coma is the inability to make any purposeful response. Scales such as the Glasgow coma scale have been designed to measure the level of consciousness.
PRIVACY
Privacy is important as it provides a secure environment for patients where they receive medical care and provide complete and accurate information, and which reinforces confidence in health care and emphasizes the importance of respect for patient autonomy
INITIATE SAFETY PROTOCOL
=> Safety is important, making sure to do it correctly and following all safety precautions in order to minimize injury to yourself or the patient.
If the client sitting in the wheelchair or in the bed, be sure to lock the brakes before starting the procedure or assessment, this is absolutely crucial for safety.
Adjusting the bed to a correct working height to maintain good body mechanics and prevent injury to your self
Check standard safety precaution, example if PPE or sterile precautions needed during assessment
HAIR, SCALP, SKIN
Skin:
The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit.
Hair:
The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed.
Scalp:
There are no nodules or masses and depressions when palpated. Check for dandruff, lice, or if there’s unusual hair distribution
EYES
inspect the eyes, eye lids, pupils, sclera, and conjunctiva
Is there swelling of the eye lids?
Is the sclera white and shiny?…not yellow as in jaundice
Is the conjunctiva pink NOT red and swollen?
Look for Strabismus and Aniscoria:
Strabismus:
Do the eyes line up with another?
Aniscoria:
Are the pupils equal in size…or is one pupil larger than the other?
Are the pupils clear…not cloudy? Normal pupil size should be 3 to 5 mm and equal
PERRLA
=>If all these findings are normal you can document
PERRLA.
Reactive to light?
Dim the lights and have the patient look at a distant object (this dilates the pupils)
Shine the light in from the side in each eye.
Note the pupil response: The eye with the light shining in it should constrict (note the dilatation size and response size (ex: pupil size goes from 3 to 1 mm) and the other side should constrict as well.
Accommodation?
Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient’s nose.
Watch the pupil response: The pupils should constrict and equally move to cross.
NARES
The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions
Symmetrical (midline, look at septum for any deviation)
Drainage (ask patient if they are having any discharge)
Use a penlight to shine inside the nose and look for any lesions, redness, or polyps
Then have the patient close one nostril and have the patient breathe out of it and do the same for the other…are they patent?
ORAL MUCOSA
To check the oral mucosa, the patient's cheek is exposed with a tongue depressor and the tissues inspected with a penlight. Healthy tissue appears moist, smooth, shiny and pink. Stensen's duct is opposite the second molar. Abnormal findings include dryness, cyanosis, paleness and Fordyce spots, and signs of disease include canker sores, Koplik's spots (an early indication of measles), candidiasis and leukoplakia.
The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.
Changes indicative of disease are seen as alterations in the oral mucosa lining the mouth, which can reveal systemic conditions, such as diabetes or vitamin deficiency, or the local effects of chronic tobacco or alcohol use. The oral mucosa tends to heal faster and with less scar formation compared to the skin. The underlying mechanism remains unknown, but research suggests that extracellular vesicles might be involved.
TEETH
The teeth should be white and free from cavities. Note: any broken or loose teeth too.
questions about toothache, hoarseness, dysphagia(difficulty swallowing), altered taste or a frequent sore throat, current and previous tobacco use and alcohol consumption and any sores, lesions or bleeding of the gums.
EOM
Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens)
The extraocular muscle function test is performed to evaluate any weakness, or other defect in the extraocular muscles which results in uncontrolled eye movements. The test involves moving the eyes in six different directions in space to evaluate the proper functioning of the extraocular muscles of the eyes.
Have the patient follow your pen light by moving it 12-14 inches from the patient’s face in the six cardinal fields of gaze (start in the midline)
Watch for any nystagmus (involuntary movements of the eye)
SYMMETRY
To assess facial symmetry, the examiner must first stand in front of the patient, looking at his/her face. While doing this, he should mentally visualize the median plane and appraise two factors.
Checking for tenderness and lumps on the trachea midline.
LUNG SOUNDS
Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E).
Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion).
Breath sounds shift from vesicular to bronchial when there is fluid in the lung itself (pneumonia).
Extra sounds that originate in the lungs and airways are referred to as "adventitious" and are always abnormal (but not always significant).
HEART SOUNDS
S1: normal: closure AV, start systole, heard all over, loudest apex
S2: normal: closure of semilunar valves, end systole, all over but loudest base, “dub”
S3: extra heart sounds: vibrations that come from filling ventricles, start diastolic usually; audible in children, young adults, pregnant women – otherwise may be indicative of disease
S4: extra heart sounds: end of diastolic, vibrations; usually abnormal to hear – may be indicative of disease
Murmurs: Grade i-ii functional systolic murmurs are common in young children and resolve with age. Auscultate for blowing, swishing sound. Some are ‘innocent” murmurs, but most are indicative of disease. Murmurs are graded. A grade “2” murmur would be rated ii/vi.
APICAL PULSE
always examine from the patient's right side.
inspect for precordial movement. tangential lighting will make movements more visible.
palpate for precordial activity in general. you may feel "extras" such as thrills or exaggerated ventricular impulses.
palpate for the point of maximal impulse (pmi or apical pulse). it is normally located in the 4th or 5th intercostal space just medial to the midclavicular line and is less than the size of a quarter.
note the location, size, and quality of the impulse. “apical pulse has a regular rate and rhythm”
ARM STRENGTH
test strength by having the patient move against your resist ance.
always compare one side to the other. grade strength on a scale from 0 to 5 "out of five":
ask to squeeze two of your fingers as hard as possible ("grip," c7, c8, t1)
RADIAL PULSES
Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachial
pulses.
CAPILLARY REFILL
press down firmly on the patient's finger or toe nail so it blanches.
release the pressure and observe how long it takes the nail bed to "pink" up.
capillary refill times greater than 2 to 3 seconds suggest peripheral vascular disease, arterial
blockage, heart failure, or shock.
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.
BOWEL SOUNDS
Auscultation
-place the diaphragm of your stethoscope lightly on the abdomen. listen for bowel sounds. are they normal, increased, decreased, or absent? borborygmus = “growling” listen for bruits over the renal arteries, iliac arteries, and aorta.
Palpation-
begin with light palpation (1cm deep). At this point you are mostly looking for areas of tenderness. The most sensitive indicator of tenderness is the patient's facial expression (so watch the patient's face, not your hands). voluntary or involuntary guarding may also be present. proceed to deep palpation (5-8 cm deep) after surveying the abdomen lightly. try to identify abdominal masses or areas of deep tenderness.
BOWEL FUNCTION
asking the patient when was the last bowel movement, 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.
assess for gastric tube or peg tube.
URINE ELIMINATION PATTERN
assess if the patient is wearing a catheter. ask the patient if they feel any discomfort with the catheter
asses for voiding elimination pattern.
note color, odor and if there is any blood in urine.
PULSE POINTS OF THE LOWER BODY (LIST ALL OF THEM AND THEIR LOCATION)
=>check the posterior tibia and dorsalis pedis pulses on both sides. if these pulses are absent or weak, check the popliteal and femoral pulses.
Femoral – groin
Popliteal – behind knee
Posterior tibial – back of leg near Achilles tendon
Dorsalis pedis (pedal) – top of foot. Requires light touch
HOMAN’S SIGN
Flex the knee, gently press the calf anteriorly against the tibia OR dorsiflex the foot toward the thigh
Normal = no pain
Abnormal = presence of pain occurs with other conditions but a deep vein thrombosis should be ruled out.
DVT
The complete exam of the extremities should include the assessment of all the following: Unilateral calf or thigh tenderness, Unilateral calf or thigh pitting edema, Unilateral calf or thigh swelling, Difference in calf diameters > 3 cm (the calf circumference is measured 10 cm below the tibial tuberosity, Difference in thigh diameters (the thigh circumference is measured 10-15 cm above the patella), Unilateral calf or thigh warmth, Unilateral calf or thigh erythema, Palpable cord (a thickened palpable vein suggestive of thrombosed vein), Dilatation of unilateral collateral superficial veins
Localized tenderness upon palpation of the deep veins, Posterior calf, Popliteal fossa, Inner anterior thigh
LEG STRENGTH
To test the strength of lower extremities, tell the patient to bend feet toward its upper surface (dorsiflex) and then (plantarflex) bending it like a ballerina with resistance.
EDEMA
Gently compress the patient's soft tissue with your thumb over the shins and if the spot that was press 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.