NUR 325 head-to-toe assessment

Supplies

stethoscope, penlight, watch, gloves, wound measurement tool

introduction

perform hand hygiene

greet patient

identify with 2 PATIENT IDENTIFIERS

greeting patient

knock

greet, ask how they prefer to be adressed

introduce name and role

explain planned task and estimate duration

provide privacy

primary survey

Airway: open? suctioning needed?

Breathing: breathing normally?

Circulation: abnormal color or moisture? cyanosis or diaphoresis?

Mental status: responsive and alert?

general survey

appearance

behavior

mood

mobility (balance and coordination)

communication

nutritional status

fluid status

chief concerns

PQRSTU

reason for seeking treatment

concerns or questions?

vital signs

HR

BP

O2

RR

temp

pain

neuromuscular assessment

subjective: H/A, dizziness, weakness, numbness, tingling, tremors

loss of coordination, balance, previous falls, difficulty swallowing

LOC, orientation to person, place, time

PERRLA

motor strength and sensation: bilateral hand grasps, upper strength and resistance, lower strength and resistance

sensation in extremities

assess fall risk

HEENT assessment

subjective: problems with teeth, gums, use of glasses, hearing aids, dentures, difficulty seeing, blurred vision, trouble hearing, ringing in ears

inspect external eye and ear

inspect oral cavity for lesions, tongue position, moisture, oral health

ask patient to swallow

palpate lymph nodes

cardiovascular assessment

subjective: chest pain, SOB, edema, palpitations, calf pain, pain in feet or lower legs when exercising

inspect:

face, lips, extremities for pallor or cyanosis

neck for JVD

bilateral extremities for color, warmth, sensation

lower extremities for hair distribution, edema, signs of DVT

palpate:

pulses bilaterally

nail beds for cap refill

auscultate:

5 auscultation area of heart

note rate and rythmn

use bell and diaphragm

identify S1 and S2 and unexpected findings

measure apical pulse for 1 minute

respiratory assessment

subjective: SOB, cough (dry or productive), smoke?

inspect:

LOC, signs of irritability, restlessness, anxiety, confusion

breathing pattern: rate, rhythmn, effort, depth of breathing

signs of difficulty breathing: nasal flaring, accessory muscles, pursed lip breathing

skin color of lips, face, hands, feet

trachea (midline?)

symmetrical chest movement

auscultate:

compare sounds side-to-side and note any adventitious sounds

oxygen?:

note if on RA or on oxygen during exam

document name of device, current flow rate, and or FiO2

inspect for skin breakdown due to device

tracheostomy?:

document condition of site and characteristics of sputum

abdominal assessment

subjective: pain? cramping, nausea, vomiting, constipation, loss of appetite, difficulty swallowing, LBM, changes in pattern or consistency, presence of blood or dark stool

pain or problems with urination, leakage of urine

inspect:

general contour and symmetry of abdomen, distention?

auscultate:

4 quadrants for one minute note hypoactive or high pitched sounds

palpate:

lightly for tenderness and masses

analyze weight trend and 24 hr I+Os

enteral tube?:

assess tube insertion site, tube placement, amount of enteral feeding/fluids administered during shift

indwelling urinary catheter?:

assess output and urine characteristics, document continued need

ostomy?:

condition of stoma and peristomal skin, amount and characteristics of output during shift

integumentary assessment

subjective: skin concerns? itching, rash, unusual mole or lump

inspect:

overall skin color and note pallor, cyanosis, jaundice, erythema, bruising, moisture, turgur

IV site?:

assess insertion site for redness, warmth, tenderness, induration

if infusing document type and amount

assess:

skin breakdown in pressure points

stage 1-4

wound?:

perform wound assessment

palpate:

temperature, moisture, texture

if erythema or rash: assess for blanching

edema:

document depth and time of indentation grade 1-4

ensure safery measure prior to leaving room

call light within reach

bed is low and locked

side rails are secured

table and personal items close by

room is risk-free for falls