Head to Toe Assessment + Safety and Documentation Lesson Plan

What are the four assessment techniques?

Inspection, palpation, percussion, and auscultation.

When are head to toe assessments done?

At the first point of contact during shift, after that q4h, then do focused assessments.

What is included in a head to toe assessment?

• Wash hands, introduce, identify patient, scan room

• Vitals: T, P, RR, O2, BP, pain, telemetry

• Neuro: LOC, A&Ox4, extremity strength x4, PERL

• Cardiac: skin color/warmth, cap refill x4, pulse strength x4, edema, heart sounds

• Respiratory: lung sounds, SoB?, cough/sputum?

• GU: auscultate, palpate, last bowel movement?, nausea

• GI: describe urine, discomfort?, incontinence?

• IV: check site, ITRACE, tubing dates

• Activity level: 1p, 2p, etc

• Fall risk assessment: confused, IV pole, weakness, medications)

• Psychosocial: anyone visiting, support system?

• Reposition

• Exit routine: bed low, call light, side rails 2-3, bed alarm

What is included in a fall risk assessment?

Age, fall history, elimination, medications, patient care, mobility, and cognition.

What are restraints?

Any method that reduces the patient’s ability to move; only used when alternatives are ineffective.

What two things are required when using restraints?

A doctor’s order and q15min monitoring.

What are the different restraints?

Enclosure beds, mitten restraints, bed rails x4, soft wrist restraints, freedom splints, and chemical restraints (ativan, geodon, haldol).

What are the alternatives to restraints?

Rule out causes, invite family, reduce stimulation, identify patient’s room, bed alarm, block areas, walk freely in safe area, offer frequent toileting, diversional activities.

What is sepsis?

Overwhelming systemic response to an infection that can cause vasodilation and shock; late stages lead to organ failure and death.

What are the SIRS (systemic inflammatory response sydrome)?

• temperature less than 36°C (96.8°F) or a temperature greater than 38°C (100.4°F)

• respiratory rate greater than 20

• heart rate greater than 90

• WBC greater than 12000 or les than 4000

If two or more SIRS are recognized, what should the nurse call for?

Code sepsis and implement the 1 hour sepsis bundle.

What is in the 1 hour sepsis budnle?

• Measure lactate level: greater than 2mmol/L = organ failure

• Obtain blood cultures before antibiotics

• Administer antibiotics

• Begin 30ml/kg normal saline IV bolus

• Vasopressors if hypotensive

When and how should you document?

• Document in military time

• Document objectively

• Document interventions followed by response to interventions

• Document time recorded and time occurred

• Document incidences and assessments

• Never document interventions before carrying them out

• Any change in pts status

In what scenarios should you always write a nursing note?

• Admissions, transfers, and discharges

• When a procedure is performed

• When receiving a postop patient

• When communicating with a healthcare provider

What should you do if documenting on paper and error occurs?

Draw straight line through error, write “Error” + your initial, and then add proper documentation.

What is the DAR format for nursing notes?

Data (assessments), action, and response (what happened after).