Head to Toe Assessment PDF

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Head to Toe Assessment ●

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LOC: Level of consciousness ○ Alert = ○ Drowsy = ○ Lethargic = ○ Stuporous = ○ COma = no response from person, possibly pain if anything Orientation: ○ Person: Name and DOB ○ Place: Do you know where you are? City and facility name ○ TIme: What is today’s date? If know the month and the year then that’s okay ○ Situation: Why are you here? Who is the president?

* if you have a non-verbal patient then you can put UTA (unable to assess) ● ● ● ● ● ● ● ● ●

Vitals: Temp = R= P= SaO2 = BP = Last BM = Smoker = when did you stop smoking? How many packs per day (if you are a smoker)? Memory: ○ Short-term = Three words or what you ate for breakfast? Ocean Desk Tractor ○ Long-term = How many kids do you have? What did you do for a living?

* If vitals are within normal range then you can put “short term memory is intact” HEAD ● Hair/Scalp = Any bumps, lice/bugs, lesions, hair is greasy or not, normocephalic (proper shape) ● Eyes/Intact = Have both eyes, glasses vs. contacts, trouble seeing or blind ○ -PERRLA = Pupil, Equal, Round, Reactive to light, and Accommodation (Follow penlight to make them cross-eyed) ○ -EOM = Extraocular Muscles (draw the H and can only move their eyes) ○ -Nystagmus = ● Ears = looking for drainage (clear), hard of hearing, symmetry, hearing aids or not ● Nose = Patent (if they are able to breathe through their nose), nose should be midline, any skin stuff, smell (have them smell rubbing alcohol), “smell intact or smell not intact” ● Mouth = moisture level (no cracks or lesions), the color of the lips (should be light pink), pale lips = low iron/low blood level, blue=lack of oxygen

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Smile = checking for stroke (could also be their baseline, make sure to double check before calling a code) ○ Stick out Tongue = (intact, pink and moist) moisture level, no lesions or cuts, etc. Mucous Membranes = intact, pink and moist (what is should be looking like) Dentation = checking for any caries (caries, missing teeth, dentures, no teeth (absent, and no dentures) Sinuses = If sinuses are inflamed then tenderness can be present, if there is congestion and/or pressure Sensation = light touches around their face with their eyes closed, may not be able to say R/L but are able to point to where you’re touching, if they have trouble feeling you can say diminished

NECK ● Lymph Nodes = palpable if you can feel them (check for any tenderness if so) or nonpalpable if you can’t feel them ● Thyroid = we are not checking for that ● Carotid Pulse = just checking to see if it is there, if you don’t feel a pulse, check code (DNR or full code) and start CPR, check one at a ● JVD = Jugular Vein Distention, you can see their jugular vein (abnormal), can be caused by heart failure or fluid overload ● Trachea Midline = current collapsed lung (opposite of whatever lung is collapsed) CHEST ● Aorta = Right side, upper side ● Pulmonary = Left side ● Erb’s Point = ● Tricuspid = ● Mitral = ● Apical Pulse = listening for a full minute, we don’t have to do these every time, Digoxin (must check before giving to a patient) ● Arrhythmia = irregular heartbeat → can be very distant, may have trouble hearing if they are obese, murmur (swishing sound) caused by a whole in the heart or caused by a disorder with the values → too constricted (stenosis) or regurgetation → valves are not closing all the way ● Breath Sounds: ○ Listen to the front and back (right= 3 lobes, left = 2 lobes) ○ Upper, middle and lower lobes need to be checked ○ Normal lung sound = clear or diminished ○ Common with elderly ○ Crackles = rice krispies, caused by fluid in lungs, starts in lower lobes then moves up, fluid in lungs can be caused by aspiration, HF; fine crackles are quitier and coarse crackles are louder ○ Wheezes = whistling sound, narrowing of the airways, upper lobes, caused by asthma and COPD, bronchitis, emphysema

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Cough/Sputum: Is the cough productive or not productive? What is the color of sputum if productive? How much of sputum? Consistent sputum or no? Chest Symmetry/Expansion: Place your hands on their back along their spine and check when they breathe if your thumbs move the same distance Skin Turgor → Check on the clavicle or on top of the hand. Checking for skin elasticity and hydration. If skin stays up you want to time how long it takes to come back down. If skin stays up it is called “tenting”. Dehydration and old age can cause tenting.

ABDOMEN *Inspection, Auscultation, and Palpation ●

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Inspection: Just looking at the abdomen for any hernias, moles, skin color, distention, look at the shape of the abdomen → sunken, rounded, flat, and protuberant (really large). Auscultation: ○ Hypoactive = one to two gurgles ○ Active = hear a gurgle every two seconds ○ Hyperactive = constant gurgle Palpation = soft and non tender (normal) Percussion = Don’t have to worry about it!

UPPER EXTREMITIES ●

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Pulses: Always start with the most distal aka Radial ○ Radial = ○ Brachial = ○ Check for the strength ■ +1 = Thready ■ +2 = “normal” ■ +3 = bounding (barely need to feel it in order to check it) ○ Make sure right and left are equal Hair Distribution: equal distribution, normal for ethnicities Sensation: Intact if they can feel Temperature vs. Trunk = basically feeling the temperature of their hands to their trunk Capillary Refill = check on their fingernail, press and turns white then goes back to pink ○ Should be less than 2 seconds to go back to pink = normal ○ If longer just make sure to report that number Grip: Strong or weak, equal or not Muscle Strength: ○ Strong = “normal” ○ Weak or Absent if they can’t move at all ROM:

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Left or Right and Active or Passive Check for pain and stop if they begin to have any

LOWER EXTREMITIES ● Palpate Pulses: ○ Dorsalis Pedis ○ Posterior Tibialis ○ Popliteal ○ Femoral ● Hair Distribution: Is it equal on both sides and do they have any or none at all? ● Edema = pitting vs non-pitting (press on it and leg go and it doesn’t go back) ○ Pitting edema: ■ +1 = tres ■ +2 = mild ■ +3 = moderate ■ +4 = severe ○ Edema can be caused by CHF, Peripheral Vascular Edema, etc. ● Temperature vs. Trunk: Warm or Cool? ● Capillary Refill ● Muscle Strength ● ROM: PAIN ● ● ● ● ● ● ● ● ●

Type of pain: Acute or Chronic; Intensity (0-10) Location: If it radiates to other places make sure to mention it Duration: Acute or Chronic Characteristics: Dull, Sharp, Aching, Radiating, Precipitating Factors: what caused the pain? Nonverbal cues → grimacing, withdraw, etc. What makes it better? What makes it worse? Does it affect your sleep?

SKIN ● ●

Description: Can be clean, dry, and intact (CDI) ○ Probably going to have fragile skin Any skin issues: ○ Skin spots, moles, skin tags, dryness level

OTHER

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Gait→ Wheelchair, walker, 1 or 2 person assists Balance: Steady or unsteady

URINARY...