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Head to Toe Assessment - Coggle Diagram
Head to Toe Assessment
Initial steps
Mentally Review Procedure, gather supplies, check doctor order, check the chart, wash hands.
• Orientation
Person, Place and Time
• LOC
Alert, Sleeping..
• Privacy
Close the door, close the curtain
• Initiate safety protocol
• Hair, scalp, skin
Bed to working height, lock wheels. Hair (dandruff, flakes), Scalp(cuts, bruising), Skin (breaks, tears, surgical sites)
• Eyes
Blood shot, tears, dry
• PERRLA
Pupils are equal, round and react to light and accommodate
• EOM
Extra ocular moment is normal
• Nares
dryness, cuts, congestion
• Oral Mucosa
pink, moist
• Teeth
w/o dental carries, cracks, missing teeth
• Symmetry
face is symmetrical, no signs of stroke
• Lung sounds
Normal, no wheezing
• Heart sounds
normal, no murmurs
• Apical pulse
Normal, no murmurs
• Arm strength
bilaterally strong, push and pull
• Radial pulses
bilaterally strong, no palpitations
• Capillary refill
less than 3 sec refill on finger nails
• Skin turgor
elastic, rebound within 3 seconds
• Bowel sounds
normal, not hypo/hyper active. Present in all 4 quads
• Bowel function
Normal for the patient, type of stool, frequency
• Urine elimination pattern
pain, discoloration, frequency
• Pulse points of the lower body (list all of them and their location)
temporal artery (temples), carotid (neck), apical (apex of heart), brachial (inside elbow), Radial (wrist along thumb line), Femoral (inside upper thigh), popliteal (behind knee), Posterior tibial (outside of the ankle), pedal (top of foot)
• DVT
Redness, swelling, pain, heat on calf
• Homan’s sign
Grab the calf while performing dorsiflexion and see if the pt has pain
• Leg strength
Bilateral, push and pull, no pain
• Edema
check on ankle, +1 or +2
• Final steps of assessment
Clean up, restore unit, bed back to lowest level, raise head of bed as pt likes, place call light within reach.