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Head to toe assessment - Coggle Diagram
Head to toe assessment
Initial steps
Mentally review the procedure
Check the chart
Gather supplies
Perform hand hygiene
Introduce self to patient
Introduce self to patient
Identify patient correctly
Assess orientation
Person,place/situation,time
Explain procedure
Lung sounds
Auscultation
Anterior and posterior
Radial pulse
Palpitate pulse
LOC
Alert
Lethargic
Confused
Privacy
Close curtains to provide privacy
Safety protocol
Lock bed wheels
Lower the bed
Working height
Hair,scalp,skin
Lesions,bruises,scarring
Eyes
Drainage
PERRLA
Pupil size
EOM
Reaction to light
Nares
Mucus
Oral Mucosa
Color and moisture
Teeth
Dentures
Symmetry
Facial
Heart sounds
Pitch and timing
Apical pulse
Apex
Arm Strength
Pain
Deformity
Capillary refill
Refill returns after 3 sec
Skin Tugor
Elasticity
Bowels
Hyperactivity
Urine pattern
Input and output
Pulse points
Pedal
Popiteal
Dorsalis pedis
Posterior tibial
DVT
Deep vein thrombosis
Homan's sign
Dorsiflexon
Leg strength
Bilateral
Edema
Pitting
Final step
Wash hands
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