Head to Toe Assessment 114

kelsscoot's version from 2015-11-23 20:01


Question Answer
Introduction (3)Greet pt., use 2 forms of pt ID and wash hands.(Name, DOB)
Mental StatusIs patient alert and oriented? (How are you today? Do you know where you are? Do you know why you're here today?)
Vital SignsTemperature, Pulse, Respirations, B/P 2 step, and Pulse Ox)
PainScale 0 - 10 (are you in any pain today?)
Integumentary general Color, Turgor, Texture, Temperature, capillary refill, hand symmetry (squeeze)
Integumentary Pressure points/Skin breakdown (5)Back of head, elbows, Coccyx, Hips, Both heels
Braden ScaleHow's you're diet? (Ask about nutrition)
HEENT Head, Ears, Eyes, Nose, & Throat
Pupils & ConjunctivaPERRLA - Pupils equal, round, reactive to light and accommodation
VisionGlasses? Contacts? any vision problems?
HearingHearing Aids? any hearing difficulties?
Noselook up nose, ask about sense of smell (How is your sense of smell?)
Mouthmucous membranes, teeth, dentures, have pt smile for symmetry
RespiratoryLung Sounds, 8 in the front, 10 in the back, correct placement and side to side method
Carotid Arteriespalpate pulse (neck one at a time), Auscultate for bruits with Bell AND Diaphragm
Heart Sounds (5 locations)get all 5 Key locations
5 Key locations of Heart soundsAortic - R 2nd, Pulmonic - L 2nd, Erb's point - L 3rd, Tricuspid - L 4th, Mitral - L 5th (only one that is ICS midclavicular line).
Pulses (3)Check Apical for 1 full minute (L 5th ICS midclavicular line), radial, & pedal
EdemaPalpate for edema bilateral ankles
Capillary refillFingernails and Toenails
GI/GenitourinaryAuscultate bowel sounds in all 4 quadrants in order (RLQ, RUQ, LUQ, LLQ), Palpate abdomen in all 4 quadrants
Last Bowel movement (4)date/when, color, consistency, normal for this patient?
Urinary eliminationdate/when, frequency, uregency, burning?
MusculoskeletalROM: Active or passive in upper and lower extremities. Have pt grab examiner's hands and squeeze, pedal pushes together at same time.
Cranial NervesDraw 3, Demonstrate. Gross motor: balance and gait. (Pt get up and walk across room and return, have pt walk heel to toe, then on toes, then on heels with patient looking straight ahead and not at floor.