Head to toe assessment PDF

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Summary

steps to head to toe assessment...

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Hello, my name is Sarah, and I will be your nurse today o Can you tell your name and date of birth?

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What brings you today? Can you tell me what today is and who the current president is?

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Vital signs – take temperature, put blood pressure cuff on (say out loud), pulse and respirations (1 min -30 sec pulse, 30 sec reps. X 2) o “pulse is strong and regular, equal bilaterally”

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Head- PERRLA, accommodation, and H test

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Smell- close eyes and one nostril

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Mouth- smile or puff out cheeks

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Finger to nose check

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Ask to swallow

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Shrug your shoulders for me

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Strength test – arms o “Strength is strong and equal”

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Palpate (with back of hand) down the arm

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Skin turgor – arms

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Feel radial pulses o “3+ and regular, equal bilaterally”

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Squeeze fingers and capillary refill (both sides)

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Ask pt to sit up and palpate anterior and posterior upper region o Listen to heart sounds and lung sounds (full inspiration and expiration)

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Ask pt to lay down and auscultate abdomen (LRQ, URQ, ULQ, LLQ)

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Vascular sounds (with bell)

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Palpate abdomen (LRQ, URQ, ULQ, LLQ)

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Palpate legs

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Pedal pulse

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Cap. Refill

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Push down on my hands like your driving a car.

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Take your heel to the other chin...