Head to Toe Assessment Checklist PDF

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Head to toe assessment prep for video and HESI...

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Course: BSN 246

Skill Video Checklist

Semester: Spring 2021

-Hand hygiene and don gloves. Introduce yourself to the patient and correctly identify your patient. Provide privacy. General survey of patient’s overall status. ● Vital signs (heart rate, blood pressure, temperature, pulse ox, respiratory rate) ● Pain assessment

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HEENT Observe color of lips and moistness Inspect teeth and gums Assess buccal mucosa and palate Examine Tongue Examine uvula Examine tonsils Palpate nose and assess symmetry Check Septum and inside nostrils Verify patency of nares Check patient’s sense of smell Palpate sinuses Assess patient hearing with whisper test Tuning Fork test (Weber’s test, Rinne test) Look inside ears Assess ear discharge and tympanic membrane Check conjunctive and sclera Assess eye symmetry PERRLA Check vision with Snellen Chart Palpate lymph nodes Observe and palpate trachea and neck Check for Jugular Venous Distention Check neck’s range of motion Check shoulder shrug with resistance

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Respiratory Listen to lung sounds front and back Assess respiratory expansion level and symmetry Ask about coughing Palpate thorax Assess work of breathing

Cardiovascular ● Palpate the carotid and temporal pulses bilaterally ● Listen to heartbeat ● Check pulses in arms/legs/feet including, Radial Femoral

Course: BSN 246

Skill Video Checklist

Semester: Spring 2021

Posterior tibial Dorsalis pedis ● Check capillary refill on fingernails/toenails

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Gastrointestinal/Abdominal Inspect abdomen Listen to 4 quadrants of abdomen for bowel sounds Palpate 4 quadrants of abdomen for pain/tenderness Ask about problems with bowel or bladder Ask when they had their last bowel movement

Musculoskeletal ● Assess range of motion and strength in arms/legs/ankles/back ● Assess sharp and dull sensation on arms/legs ● Assess for pain in any joints

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Neurological Alert and oriented x3 Assess gait Check coordination Assess reflexes Check Glasgow Coma Scale score

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Skin, Hair and Nails Check skin turgor Check for lesions, abrasions, rashes Check for tenderness, lumps, lesions Check if patient is pale, clammy, dry, cold, hot, flushed Check boney prominences for skin breakdown Check for cracking or denting in nails Check for missing or thinning hair

Hand hygiene and remove gloves. Provided appropriate education that was indicated during exam. Anything else you wish you had mentioned or assessed during your video that perhaps you forgot to mention?...