Head-to-Toe Assessment - Vocabulary Flashcards (Video Notes)

Head-to-Toe Assessment

  • Focuses on a comprehensive head-to-toe assessment.

The Power of All Types of Communication

  • Emphasizes the importance of using all types of communication in assessment and interaction.

Overcoming Nervousness

When Does Your Assessment Start?

  • Poses the question: When does the assessment start?

Remember Your Cultural Competency

  • Consider: Lifestyles, Culture / Religious Beliefs.

How Do You Introduce Yourself?

  • Key steps:
    • Wash your hands.
    • Inquire the patient’s name and date of birth.
    • Ask what they would like you to call them.
    • Ask if they are experiencing any pain.

How Do You Assess for Pain? (PQRST)

  • P – Provocation: What triggers or improves pain?
  • Q – Quality: Describe the pain.
  • R – Region: Where is it? Does it spread?
  • S – Severity: On a scale from 0−100-10?
  • T – Timing: When does it occur, how long does it last?

Orientation Assessment

  • Questions to assess orientation:
    • What is your name?
    • What is your date of birth?
    • Where are you?
    • Who is the President of the United States?
    • What is the date/month?
    • What brings you in today?
  • Note: Can substitute with another general knowledge question.

Assessment of the Head

  • Inspect hair and head for lumps, bumps, breakdown, or lesions (including lice, do not inform patient).
  • Check pinna and behind ears for skin breakdown, drainage, or earring aids.
  • Conduct whisper test.
  • Assess lymph nodes and thyroid.

Cranial Nerves I-VII

  • I – Olfactory: Smell.
  • II – Optic: Snellen chart, visual field (Visual Acuity).
  • III – Oculomotor: Eye movement (PERRLA).
  • IV – Trochlear: Eye movement down and laterally (6 cardinal gazes).
  • V – Trigeminal: Chewing or facial sensation.
  • VI – Abducens: Eye movement (6 cardinal gazes).
  • VII – Facial: Facial expressions.

Cranial Nerves VIII-XII

  • VIII – Vestibulocochlear: Hearing and balance (whisper test, observe gait).
  • IX – Glossopharyngeal: Gagging and swallowing (say "Ahh", observe palate, swallow).
  • X – Vagus: Swallowing; sensation in pharynx and larynx.
  • XI – Spinal Accessory: Shoulder shrug and head rotation.
  • XII – Hypoglossal: Tongue movement and speech.

Assess the Extremities Bilaterally

  • Upper extremities:
    • Assess arms, brachial and radial pulses.
    • Check elbows for movement and breakdown.
    • Capillary refill on fingers should be <3 ext{ seconds}.
    • Check skin turgor (hand/forehand, or chest if >65).
    • Check grasp, push, pull.
  • Lower extremities:
    • Check femoral, popliteal, pedal, and tibial/fibular pulses.
    • Assess legs for redness, pain, warmth, swelling.
    • Assess for pitting edema (degree if present).
    • Check heels, capillary refill on toes, and between toes.
    • Remove TED stockings for full assessment (schedule: 12exthoursonext/12exthoursoff12 ext{ hours on} ext{ / } 12 ext{ hours off}).