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Head-to-toe - Coggle Diagram
Head-to-toe
Initial steps
performing hand hygiene
• Orientation
patient can state name of place and time at the moment
• LOC
patient is conscious
• Privacy
curtain or doors are closed
• Initiate safety protocol
check that beds or chairs are locked
• Hair, scalp, skin
pain in the leg
• Eyes
• PERRLA
eyes are able to follow objects
• EOM
facial symmetry is even and straight
• Nares
nares could have infection
• Oral Mucosa
sores or blisters within mouth
• Teeth
discoloration
• Symmetry
discoloration iin urine
• Lung sounds
cuts, bruises or abrasions
• Heart sounds
heart sounds is clear and
• Apical pulse
eyes are reactive to light
• Arm strength
strength should be bilateral on both sides
• Radial pulses
pulse should be between 60-100
• Capillary refill
capillary refills return quickly
• Skin turgor
searching for any signs of dehydration
• Bowel sounds
absent bowel sounds
• Bowel function
bowel is regular and
• Urine elimination pattern
can be absent of lung sounds
• DVT
pain in lower leg
• Homan’s sign
• Leg strength
strength is the same on both legs
• Edema
water retention
• Final steps of assessment
assessing patient before
• Pulse points of the lower body (list all of them and their location)