Nursing Head-to-Toe Assessment Checklist

Flashcards covering key vocabulary and concepts from the Nursing Student Head-to-Toe Assessment Checklist, designed for exam preparation.

GCS Scale

A neurological scale that aims to give a reliable, objective way of recording the conscious state of a person (minimum score of 3).

General Survey

Initial assessment of overall appearance, posture, hygiene, and level of distress upon entering a patient's room.

Hand Hygiene

The act of cleaning one's hands with soap and water or an alcohol-based hand rub; performed before and after patient contact.

Patient Identification

Confirming a patient's identity using two identifiers (e.g., name and date of birth) before procedures or care.

PERRLA

Acronym used to describe normal pupil assessment: Pupils Equal, Round, Reactive to Light, and Accommodation.

Vital Signs

Key physiological measurements including temperature, pulse, respirations, blood pressure, pain assessment, and O2 saturation.

Level of Consciousness (LOC)

Assessment of a patient's awareness, typically checked by asking for orientation to person, place, time, and situation.

HEENT

Acronym for Head, Eyes, Ears, Nose, Throat, a section of the physical assessment.

S1 Heart Sound

The first heart sound, often described as 'lub,' representing the closure of the mitral and tricuspid valves (right side of the heart).

S2 Heart Sound

The second heart sound, often described as 'dub,' representing the closure of the aortic and pulmonic valves (left side of the heart).

Capillary Refill

A test that measures the time it takes for color to return to an external capillary bed after pressure is applied, usually assessed on fingertips (<3 seconds).

Peripheral Pulses

Pulses felt distant from the heart, such as radial, pedal, dorsalis pedis, and posterior tibial pulses.

Adventitious Sounds

Abnormal sounds heard during auscultation of the lungs, such as wheezing, crackles, and rhonchi.

Anterior

An anatomical directional term meaning nearer to the front of the body.

Posterior

An anatomical directional term meaning further back, nearer the rear/hind end of the body.

Lateral

An anatomical directional term meaning to the side.

Range of Motion (ROM)

The full movement potential of a joint, assessed as active (by patient) or passive (by examiner).

Turgor

The elasticity of the skin, assessed to determine hydration status.

Pressure Injury Risk Areas

Body locations prone to developing pressure injuries, typically over bony prominences like heels, sacrum, and elbows.

Documentation

The accurate recording of all assessment findings and care provided to a patient.