Head To Toe Assessment Guide PDF

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Head to Toe Nursing Assessment Guide...

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HEAD TO TOE ASSESSMENT GUIDE

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Head to Toe Assessment  Perform Hand Hygiene and Provide Privacy to patient  PRESENT YOURSELF

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-Hello, my name is Randy Chavez and I need to perform a head to toe assessment on you. Is that ok with you?

 LOOK AT PATIENT’S ARM BAND

- (This will help you to have the right patient) -Ask Patient all personal information in the Band to help you check their NEUROSTATUS  -Can you tell me where we at?  -Can you tell me what we are doing today?  -Can you tell me who is the President of the U.S? (If Patient responds to all questions correctly, you can say that patient is ORIENTED AND ALERT x 3)  VITAL SIGNS

-Heart rate (60-100 bpm) -Blood Pressure (119/79) -Temperature (98.6) -Oxygen Saturation (75-100 mm of mercury) -Respiratory Rate (12-20 Breaths per minute) -Patient Pain Rate  Ask Patient: -Are you having any pain on a scale of 0-10, zero for the less pain and 10 for the worse pain you have ever had?  COLLECT HEIGHT, WEIGHT, BMI

BMI: -less than 18.5 (underweight) -more than 30 (obese) WHY WE ASK ALL THESE QUESTIONS?... -Why are we asking all these questions and taking vital signs to the patient? A/ The meaning of all done above is to collect all information from the patient and check for: -Patient’s Emotional Status: (are they calmed, agitated, drowsy?), in fact just to see what’s going on with the patients.

-To check if they look their stated age. -To check if the skin color matches their ethnicity? -To check if they understand all the questions and see if they can hear well, or if is a delay on their responses. -To notice while talking any masses, lesions, amputations, skin sweaty. -To check if their hygiene is good?

HEAD TO TOE ASSESSMENT GUIDE -To check if their posture is good?

-To check for any abnormal smell.

Then move on to HEAD     

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First, Inspect the head. Look for Skin Color o If is nice and pink? Check that head is in size with the body Check for any abnormal or twitching of the face that Patient cannot control by himself or does involuntary Check that face is symmetrical (like bell’s palsy and people with Stroke)

Look for Eyes on the Same Level Look at facial Expressions and check CRANIAL NERVE # VII (7) FACIAL, performing a facial nerve check. HOW TO CHECK THE NERVE #7 -ASK patient: Close your eyes tightly and open them up. -ASK patient: Smile for me -ASK patient: Round for me -ASK patient: Pop out your cheeks Palpate the HEAD. (Cranium) --Wearing gloves: -Check for any masses, indentations, or infestations -Check for Skin Breakdown -Check inside the Hair (for lies) or baldness (alopecia) Find Temporal Artery and feel them bilaterally. While in that area, Check for CRNIAL NERVE # V (5) TRIGEMINAL. (responsible for mastication and some movements) HOW TO CHECK THE NERVE #5 -ASK patient: to bite down hard and feel the temporal muscle and mystical muscle. -ASK patient: Try to open mouth over resistance. Inspect and Palpate Sinuses by putting pressure -ASK the patient: Do you feel any pain when I press here?

Then move to the EYES

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HEAD TO TOE ASSESSMENT GUIDE   

Check the eyelids, pupils, sclera, conjunctiva, and iris. Check for EYE LIDS Swollenness. Check for Sclera (should be white). If yellow, suspect Jaundice

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Check Conjunctiva -ASK patient: To look up. (Should be nice and pink)  Check EYE SOCCERS. -Are they equal? -Are there any strabismus?  Check Pupils -Are there any Anisocoric? (one pupil bigger than the other one)  Check for Pupil Measurement. -Normal Measurement should be 3-5 mm  While there, Check for CRANIAL NERVE #3 (OCULOMOTOR), #4 (TROCHLEAR), #6 (ABDUCENS) HOW TO CHECK CRANIAL NERVES #3, #4, #6 -Get a penlight and move as 6 cardinal fields of Gaze (picture below). -Look for any involuntary shaking of the eyes while following the penlight.  Check how reactive Pupils are to light. -Pupils should constrict the same on both eyes when presenting light. -If pupil normal measurement is 3 mm, should constrict to 1 mm  Check for Pupil Accommodation -ASK patient: to stare at your penlight and move it towards the midline of both eyes. -Eyes should cross and pupils should constrict When Documenting this exam, you should say that PUPILS are:  P- pupils are  E- equal  R- round and reactive to  L- light  A-and accommodate

Then move to EARS 

Inspect ears for abnormalities, redness, drainage

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HEAD TO TOE ASSESSMENT GUIDE

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Ask patient: Are you having any pain? Check for Tophi.

Palpate EARS for tenderness or pain -ASK patient: What do you feel when I touch? Use a Otoscope to inspect EAR CANAL. -Enter the Otoscope into the Ear’s Canal looking for the Cone of Light.

While in that area, Check for CRANIAL NERVE #8. (VESTIBULOCOCHLEAR) -Include one of the patients ear and while including one ear go aside and whisper 2 words, then ask patient to tell you what he have heard you saying. -Repeat the same with the other ear.

Then move to the NOSE Inspect the nose for any deviation. -ASK patient: Are you having any problems with your nose, like any drainage, pain, etc?  Check for PATENCY OF THE NSOE. -ASK patient: To cover one side of the nostrils and breathe out the other side and vice versa.  Check inside the nostrils with penlight for any drainage, redness. While there, Check for CRANIAL NERVE #1. (OLDFACTORY)- sensory smell. -Use something that smells, like Vanilla, and ask the patient to close the eyes and ask for what is that he/she smells? Then move to MOUTH,  Check for any sores on the lips  Check if they are nice and pink  Check for Lips (0xygen Saturation Level)- patients with low oxygen saturation level, lips are pale.

HEAD TO TOE ASSESSMENT GUIDE  Inspect inside of the Mouth (you will need a tongue blade) While there, Check CRANIAL NERVE #7 (HYPOGLOSAL) -ASK patient: to stick the tongue out and move it side to side?  Inspect inside the MOUTH for any Sores on Cheeks, and make sure they look nice and pink. ASK patient: Can you please open your mouth? Move tong to check both Cheeks  Check for tongue moist and Pink  Check for Beefy and Red Tongue (like in pernicious anemia)  Check for cracked tongue or dry (signs of dehydration)  Check for any lesions under the tongue. (Mouth cancer hides there) -ASK patient: Can you lift your tongue?  Check Mouth Cavities and any Broken Teeth.

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Check for Soft and Hard Palate. Check for Uvula -Make sure is nice and pink and midline While there, Check CRANIAL NERVE #9. (GLOSSOPHARYNGEAL) -ASK patient: please say -HA-Look for the Uvula to move up. -Test gag reflexes by pushing a little back and elicit a gag reflex While there, Check CRANIAL NERVE #10 (VAGUS)  Patient should talk without hoarseness and able to swallow perfectly.

Then move to NECK  Check the Trachea -ASK patient: to extend the neck up a little bit. -Check for midline -Check for any lesions (like Pneumothorax) -Check for any Lumps -Check for any thyroid problems (like Goiter)

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HEAD TO TOE ASSESSMENT GUIDE

While there, Check for CRANIAL NERVE #11 (ACCESSORY)  ASK patient: to move head side to side, up and down, and to strung shoulder while you put pressure on his shoulders.  Check for Irregular Jugular Vein Distention (IJV) -Place patient at a 45-degree angle and tell him to turn head to opposite side.  Palpate Trachea -ASK patient: if he feels any tenderness?  Palpate Lymph Nodes -ASK patient: if he feels any tenderness or lumps when you touch?

LYMPH NODES CHECK LIST           

Start at the PRE-AURICULARS (right in front of ears) Then, ARECULARS (back of the ear) Then, OCCIPITALS Then, PAROTIDS Then, JUGUAR Then, SUBMANDIBULAR Then, SUBMENTAL Then to the SUPERFICIAL CERVICAL Then make a way down to the DEEP CERVICAL CHAIN Then, POSTERIOR CLAVICULAR Then, SUPRA CLAVICULAR.

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Palpate Carotid Artery (Next to Trachea) -Do not palpate bilaterally. Auscultate Carotid Artery. -Listen with Bell of Stethoscope. (Smaller Side) -Listen for a Bruit (swishing sound) -ASK Patient: Breathe in, Breath out and hold it for me? -If you do not hear a Bruit is good.

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Then move to Upper Extremities   

Inspect for lesions, redness, and swollenness. Check for any IV’S like a central line or PIC LINE (make sure is not read and does not need any dressing) or if is not supposed to be changed) Palpate RADIAL PULSE

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HEAD TO TOE ASSESSMENT GUIDE -If pulses feel equals on both sides, you can say 2x Check for Capillary Refill. -Press down on patients nail bed and check how fast it refills -Should take less than 2 seconds to refill, when normal.  Check Skin Turgor Bobbitt -Pinch on the skin of the patient and check how fast it goes back to normal.  Check at the FINGER’S RANGE OF MOTION -ASK patient for any pain in 

the hands. 

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Check for Brachial Artery.  Feel those bilaterally. -if it was a dialysis patient and they have an IV Fistula, you would want to palpate and feel for the thrill and make sure is present. Check for MUSCLE STRENGHT  ASK patient to squeeze your fingers and hard as they can.  ASK patient to push up against your hands, as you push down against his hands. Check and test EBLOWS  Move them up and down to check for any Arthritis Check for a DRIFT.  ASK patient to stand up  ASK patient to Hold Up the Arms and close the eyes for about 10 seconds.  While doing that you check for any drift that may be caused by a stroke.

Then move to Chest   

We are looking for abnormalities like lesions or any wounds Inspect the patient’s effort of breathing  Check if they are using those accessory muscles to breathe? Look at the anterior and posterior diameter.  You want to look for that barrel chest (which is abnormal) In patients with COPD it will be increased, they have what’s called barrel chest)

Listen to Heart Sounds

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HEAD TO TOE ASSESSMENT GUIDE

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1st Auscultate in the 5 locations (where are based the valves of the heart)  -Remember the Pneumonic: All Patients Effectively Take Medicine (Aortic, Pulmonic, Herb’s  Point, Tricuspid, Mitral) Using the Diaphragm of the Statoscope, Listen to:  Aortic Valve (Located in 2 nd Intercostal Space) -Listen for LUB, DUB (S1 & S2) In this area S2 will be louder.  Pulmonic Valve (Located on left of Sternal Border at the second Intercostal Space) - Listen for LUB, DUB (S1 & S2) In this area S2 will be louder as well.  Herb’s Point (A little bid down onto the 3rd Intercostal Space) - Listen for LUB, DUB (S1 & S2)  Tricuspid Valve (Down to the 4th Intercostal Space) - Listen for LUB, DUB (S1 & S2) In this area S1 will be louder  Mitral Valve and Apical Pulse (Located in the 5th Intercostal Space and Midclavicular Line being the point of maximal impulse) - Listen for LUB, DUB (S1 & S2) - Apical Pulse (listen for a minute and count) normal adult pulse 60-100 bpm. Then switch to Bell of the Stethoscope to listen for

HEART MURMUS (looking for switching blowing sounds) -Repeat Assessment of Sounds on the same previous locations on the Chest

Then listen to Lung Sounds    

Crackles Wheezes Pleural Friction Stridor

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First, start at the Apex of the Lungs. (listen on both sides)  Ask the patient: To take a deep breath in an out while to listen.

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Second, move down to the 2nd Intercostal Space. (this will help to listen to right upper lobe and left upper lobe of lungs)  Ask the patient: To take a deep breath in an out while to listen.

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Third, move down to the 4th intercostal space (to assess the right middle lob and left upper lobe)  Ask the patient: To take a deep breath in an out while to listen.

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HEAD TO TOE ASSESSMENT GUIDE 

Then, go down to mid axillary, 6th Intercostal Space (to assess the right and left lower lobe)  Ask the patient: To take a deep breath in an out while to listen.

Auscultation

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Percussion

Then go around the lungs Posteriorly  Using the diaphragm of the Stethoscope  Listen between the Scapula and Spine  Start at the Apex and compare both sides of the lungs  Then, To assess the Right and Left Upper Lobes , Find C7 (vertebral prominence) which will be a ball and go down to T3 and go a little bit between the shoulder blade and the spine.  Then, to assess the Right and Left Lower Lobes, from T3 to T10 an inch around.

Then, we move to the Abdomen. Here sequence changes, to  Inspection, Auscultation, Palpation and Percussion.       

Have the Patient lay over his back. Ask Patient: Are you having or had any stomach issues at all? Ask Patient: When was your last bowel movement? Ask Patient: How are you urinating? Ask Patient: Do you have any pain while you are peeing? Ask Patient: Do you have any problems starting the stream? Ask Patient: Do you have any discharge? In male patients, you ask about all this to make sure there is, or there is not a prostate enlargement.

In patients with a Foley, This is the time to look at the urine and inspect the Foley by looking at the Urinary System and GI System together.

HEAD TO TOE ASSESSMENT GUIDE

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INSPECT ABDOMEN  

We are looking at the abdominal contour Also, we are going to know if there is any pulsations. (Aortic Pulsations can be seen on thin patients  Check for any masses or hernias around the belly button.  If they have a Pep tube, assess it to make sure is not red.  Ask Patient: How it feels?  Check for Ostomies. Look at the Stoma and make sure that looks rosy pink and not black brown (dusky cyanotic) color. Look and see what type of stool it’s putting out and note the smell as well. Check if the bag needs to be changed

Listen to BOWEL SOUNDS 

(with Diaphragm of Stethoscope)  Start at the Right Lower Quadrant and work your way clock wise to listen to all Quadrants.  You should hear 5 to 30 sounds per minute.  Note if sounds are normal or abnormal  Note if sounds are hyperactive (increase in intestinal activity)  Note if sounds are hypoactive (slow intestinal activity)

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Now, Listen to Vascular Sounds (with Bell of Stethoscope) When listening to Vascular Sounds, we are looking for “Bruits”    

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Aortic (little bit below xiphoid process) Renal Arteries (a little bit down from the aorta location) Iliac Artery (a little bit below the belly button) Femoral Artery (located in the groins)

Palpation of the Abdomen  1St Superficial (2 cm deep)  Feeling for any tenderness, lumps, or masses.  Ask Patient: How it feels when you touch?  2nd Deep Palpation (5cm deep)  Feeling for masses, lumps, tenderness.  Ask Patient: How it feels when you touch?

Then move to Feet 

Palpate the Feet  Feel pulses in the feet.  Posterior Tibiae (behind Feet)

HEAD TO TOE ASSESSMENT GUIDE 

Dorsalis Pedi’s (on top of feet)

If you ever can’t find the pulses use a Doppler Ultrasound Machine.  

Check Nails and press each one for 2 seconds. Check Babinski Reflexes  Use your reflex hammer to test it  We are looking for the Toes to curl with sensation (it will be a negative normal response)

THEN INSPECT THE BACK OF THE PATIENT  Have patient to stand up and turn him around and inspect.  Look for any abnormal moles, lesions, wounds, and skin breaks.

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HEAD TO TOE ASSESSMENT GUIDE

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