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Head -To- Toe - Coggle Diagram
Head -To- Toe
3 - ORIENTATION
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• A&O X4 = Oriented to Person,Place,Time & situation
verify client’s identity using correct identifiers (assess orientation; LOC- is the client alert, drowsy, lethargic, confused, obtunded, etc?).**
12 - Lungs
Auscultation of breath 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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1-Introduction
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• 2- Introduce yourselfHello, Mrs./Mr. _, my name is _ and I'm a student nurse. I'll be helping out
your nurse to take care of you today. Is that alright?
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9 -PERRLA
PERRLA-Pupils equal, round reactive
to light & accommodation
EOM - Extracular movement intact
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6 - Initiate safety protocol necessary (wheels locked, raise bed to working height, etc.).
7 - Assess condition
of hair, scalp, skin.**
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**10 - Assess nares, oral mucosa, and teeth for presence of dental caries-**
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19 - Auscultation of bowel sounds (present/absent, hyper/hypo). Palpate abdomen when
necessary: soft, firm, tense, distended, assess for pain/tenderness
20 -Assessment of bowel function. Ask for BM schedule/last BM, consistency,
etc. Note presence of an ostomy/assess stoma and skin
21 - Assess urine elimination pattern. If catheter present, note color, quality,
amount, quantity of urine and assess site, pain & discomfort. Check for patent tubes
23 - Assessment for any tenderness in one or both legs, warmth, red or discolored skin.
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**22 - Assess popliteal & pedal/posterior tibial pulses; strength of pulse, equal bilaterally.
28 - “Restore the unit” (lower bed to lowest level, tell patient where call light is, put
belongings patient needs within reach of the patient, etc.)
25 - Presence of edema. Note if non-pitting or pitting (1+, 2+…).
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30 - Exam completed within specified time limit 20-min. Instructor will stop
exam at 20-minute time limit.
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