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Head to toe assessment - Coggle Diagram
Head to toe assessment
Privacy -close door, put curtains
edema - assess skin of the legs and press, and check for pitting level 1- 2+
Eyes - check if the patient's extra ocular muscle of the eyes is intake, check pupil are round, reactive, to light and accommodation.
LOC- level of orientation- asl patient for 2 identifier, check the patient level of orientation in person ,place and time
Initiate safety protocol - lock wheel, put bed in working position
Homan's sign -assess by putting the patients knee in extended positioning forcefully dorsiflex the patient ankles.
leg strength - assess strength of both legs by holding both feet and let the patient push and pull both legs .
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DVT - assess for sign of swelling on both legs, pain and warmth. check for skin color and temperature.
Nares - check for any blockage, infections and allergies
PERRLA stand for Pupils equal, Round and Reactive to light and accommodation
Teeth - check for cavities or caries, plaque and tartar.
oral mucosa - use of penlight and tongue depressor, check if there are swelling on gums, teeth, tongue.
Heart sound - check for auscultation of heart sound located at 2nd right intercostal space at the right sternal boarder.
bowel function- ask patient when was his/her last bowel movement, check for the texture and color. check if they experience pain, and assess for peristaltic sounds on 4 quadrants of the abdomen.
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urine elimination - ask patient when did he/she voided, color and quantity, if they experience pain during voiding
Symmetry - check patients facial symmetry if its equal, from forehead to the jaws, check if there is swelling in lymph node
bowel sounds - check(palpate) for the 4 quadrants of the abdomen for soft, firm, tenderness and pain. all of the quadrant should have peristaltic sounds.
arm strength - check the strength of both arms by push and pull for resistance, let the patient grip both index finger to assess both strength.
Orientation - check the patient level of orientation in person ,place and time
EOM - extra ocular muscle, this muscles attach the the eyeball and responsible to move the eye.
apical pulse - check the pulse located at left center of the chest, just below the nipple.
radial pulse - place index and third finger to the patient inside wrist below the base of thumb, between the bone and the tendon. feel the pulse and count it for 30 seconds and multiply it by 2.
capillary refill - hold the hand higher to the heart level, press the finger nail until it turns white and take note of the time when color return after the pressure is release.
skin turgor - grasp the skin between two finger and tented it up, held it in few seconds and then release then take note of the time when the skin return normal.
Final steps of assessment - perform hand hygiene, put back the bed in low position, inform patient the location of call light, put personal belonging within reach, restore unit and document the procedure , patient participation and tolerance to the assessment.
Hair, scalp, skin - check if the is lice, cuts and bruises
Initial step - mentally review the procedure, check MAR, gather supplies, perform hand hygiene, introduce yourself