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What is the usual assessment sequence in a head-to-toe assessment?

Inspection → Palpation → Percussion → Auscultation. Remember IPPA.

What is inspection in head-to-toe assessment?.

Looking at the body for changes or abnormalities.

What is palpation in head-to-toe assessment?

Using your hands to feel for tenderness, lumps, swelling, or temperature changes.

What is percussion in head-to-toe assessment?

Tapping the body to check sounds that help identify air, fluid, or solid tissue.

What is auscultation in head-to-toe assessment?

Using a stethoscope to listen to heart, lung, and bowel sounds

What is the assessment sequence for the abdomen?

Inspection → Auscultation → Percussion → Palpation. Remember “I APP.”

What is inspection during an abdominal assessment?

Look at the belly.

What is auscultation during an abdominal assessment?

Listen to bowel sounds with a stethoscope.

What is percussion during an abdominal assessment?

Tap the belly to check sounds.

What is palpation during an abdominal assessment?

Gently press the belly to feel for pain, lumps, or swelling.

How is the assessment sequence different for the abdomen?

Inspection → Auscultation → Percussion → Palpation. Listen before tapping or pressing the abdomen because these actions can change bowel sounds.

What do the four assessment techniques mean?

Inspect = look.

Palpate = feel.

Percuss = tap.

Auscultate = listen.

What should you do before beginning the assessment?

Perform hand hygiene.

How should you introduce yourself and identify the patient?

State your name and role, then verify the patient using two identifiers.

What should you explain before the assessment?

What you will assess and what the patient should expect.

How should you provide privacy?

Close the curtain or door, use a gown or drape, and expose only the area being assessed.

How should you choose PPE?

Use Standard Precautions for every patient and select PPE based on the expected exposure.

What should you do with shared assessment equipment between patients?

Clean and disinfect it.

When does the general survey begin?

As soon as you meet the patient.

What should you assess about general appearance?

Appearance, hygiene, grooming, skin color, nutrition, body language, and mobility.

What should you observe about posture?

How the patient sits, stands, and holds their body.

What should you observe for signs of distress?

Breathing difficulty, discomfort, unusual behavior, or an appearance of being unwell.

What does LOC stand for, and what does assessing it mean?

LOC = level of consciousness. Check how awake, alert, and responsive the patient is.

Which vital signs should you obtain?

Temperature, pulse, respirations, blood pressure, and oxygen saturation.

How should you assess pain according to the outline?

Use an appropriate pain scale.

What is subjective data?

Information the patient tells you, such as pain or dizziness.

What is objective data?

Information you observe or measure, such as swelling or blood pressure.

What is a baseline measurement?

A starting measurement used to compare with later findings.

What should you do with unexpected findings?

Perform a focused assessment and report or escalate as needed.

What is a typical average body temperature

37°C, or 98.6°F. Temperature varies by person, time, and measurement route.

What temperature commonly indicates fever?

About 38°C, or 100.4°F, or higher, depending on the route and setting.

What are the common temperature measurement sites?

Oral, axillary, tympanic, temporal, and rectal.

How do you take an oral temperature?

Place the covered probe in a pocket under the tongue and have the patient close their lips.

How long do your notes recommend waiting after hot or cold intake or smoking before an oral temperature?

About 30 minutes.

How do you take an axillary temperature?

Place the covered probe against skin in the center of the armpit and lower the arm.

How is the ear positioned for a tympanic temperature?

• Adults and children age 3 or older: Pull the ear up and back.

• Children under 3: Pull the ear down and back. Follow device instructions.

What can interfere with a temporal temperature reading?

Sweat, hair, or a head covering.

When should a rectal temperature be avoided?

When contraindicated, such as with certain rectal conditions, recent rectal surgery, or bleeding risks.

What temperature information should you document?

The reading, measurement route, and relevant interventions or response.

What is the usual resting adult pulse range?

60–100 beats per minute.

Where is the radial pulse located?

On the thumb side of the inner wrist.

How should you feel the radial pulse?

Use the pads of two or three fingers and apply gentle pressure.

What should you assess about peripheral pulses?

• Presence: Can you feel the pulse?

• Rate: Beats in one minute.

• Rhythm: Regular (steady) or irregular (uneven).

• Strength: Strong or weak.

• Equality: Whether pulses feel the same on both sides.

What do tachycardia and bradycardia mean in adults?

Tachycardia = above 100 beats/min. Bradycardia = below 60 beats/min.

What is the usual resting adult respiratory rate?

12–20 breaths per minute.

What counts as one respiration?

One breath in and one breath out.

How can you count respirations without changing the patient’s breathing?

After checking the wrist pulse, keep your fingers there while watching the chest or abdomen.

How long should you count respirations?

For a healthy patient with regular breathing, count 30 seconds and multiply by 2. Count a full minute if ill or breathing is irregular or abnormal.

What does systolic blood pressure measure?

Pressure when the heart contracts; it is the top number.

What does diastolic blood pressure measure?

Pressure when the heart relaxes; it is the bottom number.

What is normal adult blood pressure?

Systolic below 120 AND diastolic below 80 mm Hg.

What is elevated adult blood pressure?

Systolic 120–129 AND diastolic below 80 mm Hg.

What is stage 1 hypertension?

Systolic 130–139 OR diastolic 80–89 mm Hg.

What is stage 2 hypertension?

Systolic 140 or higher OR diastolic 90 or higher.

How should the patient prepare for a routine seated blood pressure reading?

Rest quietly for at least 5 minutes; avoid smoking, caffeine, and exercise for 30 minutes beforehand.

How should a seated patient be positioned for blood pressure measurement?

Back supported, feet flat, legs uncrossed, and arm supported at heart level.

Where should the blood pressure cuff be placed?

On the bare upper arm, about 1 inch above the elbow crease, with the artery marker over the brachial artery.

What happens if the blood pressure cuff is too small?

The reading may be falsely high.

What happens if the blood pressure cuff is too large?

The reading may be falsely low.

Where should the stethoscope be placed for manual blood pressure?

Over the brachial artery near the inside of the elbow.

How high should the cuff be inflated for the manual listening measurement?

About 30 mm Hg above where the radial pulse disappeared during the preliminary palpation check.

How quickly should the cuff deflate?

About 2 mm Hg per second.

Which sounds identify systolic and diastolic pressure?

The first Korotkoff sound identifies systolic pressure; disappearance identifies diastolic pressure in most adults.

Can the usual palpation method measure both blood pressure numbers?

No. It estimates systolic pressure only.

When should you consider orthostatic measurements?

When the patient reports lightheadedness with position changes.

What is orthostatic hypotension?

Blood pressure drops when you stand up, which may make you feel dizzy or faint.

Within 3 minutes of standing:

• Top number (systolic): Drops by 20 or more.

• OR bottom number (diastolic): Drops by 10 or more.

What does SpO₂ measure?

The estimated percentage of hemoglobin (the protein in red blood cells that carries oxygen) carrying oxygen.

Measured with a pulse oximeter, the small device placed on your finger.

What oxygen saturation range is usually expected in your notes?

95%–100%, unless a different target is prescribed.

How do you obtain a stable finger pulse oximeter reading?

Use a suitable finger with good circulation, keep it still, confirm the displayed pulse matches the patient’s pulse, and wait for a stable reading.

What can affect pulse oximeter accuracy?

Movement, cold skin, poor circulation, nail products, incorrect placement, and differences in accuracy related to skin pigmentation.

What does A&O × 4 mean?

Alert and oriented to person, place, time, and situation.

How do you assess orientation to person?

Ask, “What is your name?”

64. How do you assess orientation to place?

Ask, “Where are you right now?”

65. How do you assess orientation to time?

Ask, “What month and year is it?”

66. How do you assess orientation to situation?

Ask, “Why are you here?”

67. What should you assess about speech?

Whether it is clear and understandable.

68. What should you check about the pupils during the neurological assessment?

Size, equality, and reaction to light; assess accommodation for PERRLA.

69. What does PERRLA stand for?

P = Pupils E = Equal R = Round R = Reactive to L = Light A = Accommodation (adjust focus when looking at near and far objects)

70. How do you assess facial symmetry?

Compare both sides at rest and during movements such as smiling or raising the eyebrows.

71. How do you assess hand grips bilaterally?

Ask the patient to squeeze both of your hands at the same time. Compare the strength of both hands to see if they are equally strong or if one is weaker.

72. How do you assess arm strength?

Ask the patient to push and pull against your hands using both arms. Compare the right and left arms to see if they are equally strong or if one is weaker.

73. How do you assess foot pushes and pulls?

Ask the patient to push their feet down against your hands (like pressing a gas pedal), then pull their toes up toward their head against your hands. Compare both feet to see if one is weaker than the other.

74. How should sensation be assessed?

Ask the patient to close their eyes, then gently touch the skin on both sides of their body. Ask if they can feel the touch equally on both sides.

75. When should you assess gait and balance?

When it is safe for the patient to stand and walk. Ask them to walk a few steps while you watch their walking, posture, and balance.

76. What is acute disorientation?

New or sudden confusion.

77. What should you do about new confusion?

Assess promptly, obtain vital signs, and escalate care based on findings.

78. What sudden findings can suggest a stroke?

Facial drooping, one-sided weakness, speech difficulty, confusion, or vision changes.

79. What should you do when stroke is suspected?

Activate the stroke or emergency response and establish the last time the patient was known to be normal.

80. What should you inspect about the head?

Head shape, size, position, and scalp.

81. What should you inspect on the scalp and hair?

Skin condition, hair distribution, and lesions.

82. What should you feel for on the scalp?

Lumps, swelling, tenderness, or unusual depressions.

83. What abnormal facial movements should you watch for?

Facial drooping or involuntary movements.

84. What should you ask about headaches?

• Onset: When it started.

• Frequency: How often it happens.

• Duration: How long it lasts.

• Severity: Pain level from 0–10.

• Associated symptoms: Nausea, dizziness, or blurry vision.

• What helps: Rest or medication.

85. What should you ask about a previous head injury?

Ask what happened (how they injured their head) and if they lost consciousness (passed out or blacked out), including for how long.

86. What pupil size is listed in your notes?

3–5 mm; size also depends on lighting, age, and medications.

87. How should pupils respond to bright light?

They should constrict, or become smaller.

88. What are direct and consensual pupil responses?

Direct = the illuminated eye constricts.

Consensual = the opposite eye also constricts.

89. What is accommodation?

The eyes adjusting to focus on a nearby object.

90. What should you ask about vision?

Blurred or double vision, other changes, onset, pain, and whether one or both eyes are affected.

91. Why are newly unequal or nonreactive pupils concerning?

• Why concerning: May indicate a neurological problem (brain or nerve problem) or an eye problem needing prompt assessment.

• Unequal pupils: One pupil is bigger than the other.

• Nonreactive pupils: Pupils do not get smaller when light shines in the eyes.