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HEAD TO TOE ASSESSMENT 8/25/2020 ARG - Coggle Diagram
HEAD TO TOE ASSESSMENT 8/25/2020 ARG
INITIAL STEPS
Mentally review the procedure, check the patient's report, and gather supplies.
Perform hand hygiene
Introduce self to client
Verify client's identity using two identifiers
ORIENTATION
Assess the orientation by asking the patient for his/her name (person), if he/she knows he is (place), if he/she knows what day, month, or holiday is it (time), and if he/she knows why is there, or reason (situation).
LOC
Level of consciousness: If client is alert,drowsy, lethargic, confused, obtunded etc
PRIVACY
First explain procedure to patient and ask permission, then provide privacy in the room (closing the curtain, door), and provide adequate light to perform the exam.
INITIATE SAFETY PROTOCOL
Check if the wheels of the bed are locked, and raise the bed to a working height.
HAIR, SCALP, SKIN
Assess the condition of the hair, scalp, and skin. Check for lice, dandruff, and condition of the hair.
EYES
Assess the condition of the eyes, for cloudiness, irritation, redness, etc
PERRLA
Check the eyes for pupil reaction to light.
EOM
Check for eye's extra ocular muscles in six different directions to evaluate for weakness and eye control movement.
NARES
Assess inside the nose for dryness and irritation and any abnormality.
ORAL MUCOSA
Ask patient to open mouth and check the oral mucosa and irritations inside.
TEETH
Check the teeth for any dental problems such as caries, or gum problems.
SYMMETRY
Assess the face, trachea midline symmetry and check for tenderness of lumps.
LUNG SOUNDS
Auscultate both anterior and posterior lung sounds, assess for quality, rate, and rhythm. Note breathing aides, check breathing pattern, chest rise symmetry, and use of accessory mucles.
HEART SOUNDS
Auscultate the heart sounds. Listen to the different valves: aorty (2nd,3rd right interspace), pulmonic (2nd,3rd left intersdpace), tricuspic ( left sternal border) and mitral (Apex).
APICAL PULSE
On the left side of chest, at 5th intercostal space and midclavicular line. Check it for a full minute. Normal pulse 60 to 100.
ARM STRENGTH
Check the arms strength (ask patient to grasp your your hands and check for push resistance, and grip strength bilaterally.
RADIAL PULSES
Check radial pulses bilaterally for a full minute ( Normal pulse 60 to 100). Check the capillary refill at the blanch of the nails (Adults less than 3 seconds, Elders less than 5 seconds).
CAPILLARY REFILL
Check the capillary refill on the feet. Press on the toenails and release it, check how long it takes for the color to come back ( normal time less than 3 seconds for adults, less than 5 seconds for elders.
SKIN TURGOR
Check the skin turgor by grasping the skin on the hand lower arm, or abdomen with 2 fingers in a tented up way, release it and note the time for the skin to snap back to the normal position. ( Normal time less than 3 seconds for adults, less than 5 seconds for elders).
BOWEL SOUNDS
Auscultate the bowel sounds ( present, absent, or hyper , hypo), Check up to 3 minutes until sound is noted. Palpate abdomen (firm, soft, tense, distended, tenderness, and assess for pain)
BOWEL FUNCTION
Ask for last BM, schedule BM, consistency, and any abnormality. Note for presence of ostomy (if present assess condition, and skin around).
URINE ELIMINATION PATTERN
Assess the urine elimination, check the color, quality, amount, pain, and discomfort. If catheter is present make sure its in place and working well.
PULSE POINTS OF THE LOWER BODY
Assess for strength of pulses on lower extremities, equal bilaterally. Popliteal (back of the knee), Pedal (top of the foot), posterior tibial (side of the foot by the ankle).
DVT
Assess for any swelling, in one or both legs
HOMAN'S SIGN
Assess for pain, warmth, red, or discolored skin in one or both legs.
LEG STRENGTH
Test the strength of the legs bilaterally (check the dorsiflex, plantarflex with resistance).
EDEMA
Check for the presence of edema on both legs. Check for non pitting or pitting 1+, 2+. Press on the edema area with your thumb for a few seconds, release it, and check the depth of the idention, and how long it takes to go back to original position.
FINAL STEPS OF ASSESSMENT
Assess the skin color, temperature, wounds, scars, dryness, rashes, redness, bruises, etc. Check the condition of incisions and wounds if present.
Restores unit( lower the bed to the lowest position, tell the patient where the call light is, and put belongins at reach of the patient to avoid falls in case patient needs them).
Perform hand hygiene, and document the results of the assessment.