Head to Toe Assessment
Health and Wellness Definitions
- Health is holistic, encompassing physical, psychosocial, and spiritual aspects.
- Wellness is achieving a balanced and satisfying state of life.
Components of Physical Assessment
- Physical assessment: hands-on examination collecting objective data.
- Health assessment: systematic data collection to determine health status and risks.
- Subjective data gathered during patient interviews.
Steps for Head to Toe Assessment
- Initial Report: Receive pass down report, clarify questions, and conduct a 60-second check on patients.
- General Survey: Immediate visual assessment of physical condition (e.g., ABCs, distress).
- Chart Review: Gather pertinent patient history and information.
- Equipment Preparation: Complete hygiene, knock before entering, and begin general survey.
Assessment Process
- Introduction: Greet patient, perform hygiene, identify the patient, and check LOC.
- Anterior Order Assessment: Includes head, eyes, ears, face, mouth, nose, and respiratory system; assess each area as per guidelines.
- Cardiovascular Assessment: Check heart rate, rhythm, and pulse points. Auscultate heart sounds in specified locations.
- Abdominal Assessment: Inspect and auscultate for abnormalities; assess perineum and urinary function.
- Posterior Assessment: Check skin integrity, mobility, and inspect back for injuries.
Completion of Assessment
- Document findings in electronic medical records, including patient's condition during assessment.
- Thank the patient, provide call light, and ensure comfort before exiting.
- Continue to monitor the patient as per acuity needs.
Additional Assessment Tests
- Peripheral pulses may need Doppler if not palpable. Key sites include Femoral, Popliteal, Dorsalis Pedis, and Posterior Tibialis.
- Apical pulse checked for irregular rhythms; take for 1 minute if necessary.