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Head To Toe Assessment - Coggle Diagram
Head To Toe Assessment
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Verify client’s identity using correct identifiers (assess orientation; LOC- is the client alert, drowsy, lethargic, confused, obtunded, etc?).
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Initiate safety protocol necessary (wheels locked, raise bed to working height, etc.).
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Assess condition of hair, scalp, skin.
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Assess nares, oral mucosa, and teeth for presence of dental caries.
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Auscultation of lung sounds both anterior and posterior; assess quality, rate, and rhythm. Take note for use of any breathing aides (i.e. O2, humidifier, respirators). Note ratio and pattern of breathing; thoracic inspection (i.e. chest rise symmetry, use of accessory muscles).
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Auscultation of bowel sounds (present/absent, hyper/hypo). Palpate abdomen when necessary: soft, firm, tense, distended, assess for pain/tenderness
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Assessment of bowel function. Ask for BM schedule/last BM, consistency,
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Assess urine elimination pattern. If catheter present, note color, quality,
amount, quantity of urine and assess site, pain & discomfort. Check for patent tubes.
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Assess popliteal & pedal/posterior tibial pulses; strength of pulse, equal bilaterally.
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Assessment for signs of DVT & Homan’s sign. Note any swelling in one or both legs, pain, warmth, red or discolored skin.
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Presence of edema. Note if non-pitting or pitting (1+, 2+…).
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Assess skin for color, temperature, wounds, scars, dryness, rashes, redness,
bruises, etc. If dressing present note condition of incision or wound and dressing date, condition.
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