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Head To Toe 1

This document provides guidance on conducting a head-to-toe assessment by checking vital signs, level of consciousness, skin, respiratory, cardiovascular, abdominal, genitourinary, lower extremity, dressings and wounds, and circulation in a systematic order. The assessment checks for abnormalities, ensures proper functioning of devices like IVs, monitors orientation and provides education tailored to the client's learning needs.

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fancyfree2011
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152 views1 page

Head To Toe 1

This document provides guidance on conducting a head-to-toe assessment by checking vital signs, level of consciousness, skin, respiratory, cardiovascular, abdominal, genitourinary, lower extremity, dressings and wounds, and circulation in a systematic order. The assessment checks for abnormalities, ensures proper functioning of devices like IVs, monitors orientation and provides education tailored to the client's learning needs.

Uploaded by

fancyfree2011
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Head-to-Toe Assessment - Initial Survey: Check ABCs LOC (Awake, alert/lethargic/unresponsive) Orientation (to person, place and time)

Neuro check (PERRLA/Glasgow Coma Scale if appropriate) Skin color (pale/pink/ruddy/cyanotic/dusky) Skin temp (cool/cold/warm/hot) Skin texture (dry/diaphoretic) Skin lesions/pressure or statis ulcers/ecchymoses: color, drainage, odors, LxWxD in cm VS T (include route), P, R, BP/5th VS = PAIN Apical-rate, S1, S2 Rhythm (regular/irregular/regularly irregular) Intensity (loud/distant) O2 and Pulse Ox Effort (easy/unlabored) Depth (deep/shallow/blowing)/Auscultation-ant/lat/post * Chest tubes/need for suctioning/advanced skills, i.e. tactile fremitus/diaphragmatic excursion if applicable Upper extremities if IV present note: gauge, solution, rate and infusion pump/controller. Assess IV site for: warmth, redness, edema, drainage or tenderness. Abdomen inspect (round/flat/obese/distended) * Any PEG, G-tube, NG-tube, Dobhoff tube? Auscultate (BS present x 4 quads? rhythm of BS normal/hyper/hypoactive and the intensity high/low-pitched) Palpate (soft/firm/hard/tender to light and deep palpation?) Abdomen (continued) Bowel: Last BM (size/color/consistency/odor) Postop flatus? Incontinence urinary or fecal or both? GU: Void/ Foley/ Suprapubic/Fr and balloon size, amount, color, presence of mucus/sediment, odor. Note patency and describe urine in dependent drainage bag tubing. Ostomy? (note condition of stoma and skin surrounding stoma/contents of ostomy bag-phalange or bag change/clients adaptation to ostomy) Lower extremities Homans sign (negative/positive) - with positive being a bad sign possibly indicative of DVT. Pedal pulses (Dorsalis Pedis/Posterior tibial, compare bilaterally, Grading (0 - +4)/check for edema) pitting (+1 - +4)/nonpitting? Capillary refill (brisk/sluggish-how long, >3 seconds) ROM, Gait Dressings, drains or wounds should be assessed and documented in the order they appear in the assessment i.e. RUE RLE. If a circulation check is done, place that information in the order it was assessed. Circulation Assessment, include: color/warmth/pulse/ capillary refill/movement and always compare bilaterally. Client Education: Include how client learns best, teaching done and client response.

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