Head to Toe Assessment.

Head to Toe Assessment

Components Overall, Head, Neuro Posterior thorax Anterior thorax Heart
Abdomen GU/Elimination Upper Ext Lower Ext Safety

Safety First! Always Wash your hands
Wear gloves if coming in contact with body fluids Side rails up x 2 Put one side down while working, raise if you leave the side of the bed Bed/wheels locked Bed should not move when you lean against it Bed low Put the bed in the lowest position possible

General Appearance Is the patient in any distress? Assess LOC
Alert, spontaneous eye opening Respiratory Pattern Unlabored Labored General Skin color Normal Cyanotic Position HOB elevated Mood Does pt have Tubes/Lines/Drains? Oxygen device NG tube IV’s Foley TED Hose/Compression device

Introductions Student Name, school Purpose Patient
Care for pt Assessment, medications, hygiene, linen change Patient Ask name and DOB, compare to armband Assess orientation: person, place, and day/time

Vital Signs Temperature Normal 97.0-100.0 Pulse Normal 60-100
Respirations Normal 16-24 If you are having difficult listen Blood Pressure Systolic normal Diastolic normal 60-90 O2 Sat Normal % Abnormal Vital Signs Recheck first Notify nurse Notify instructor

Pain Scale No Pain 0/10 Denies pain 0/10
Pain scores 1-10 require symptom analysis Location Quantity Quality Onset, Duration, Frequency Measures that relieve Measures that aggravate

Head and Neck Is Face Symmetrical? Pt with right sided paralysis
Is Speech Clear? Any Visual impairments? Any Hearing impairments? Oxygen device Type LPM Worn correctly Any damage to skin: nares/face NG Tube/Feeding Tube Which nare is it in Any skin damage to nare Is it attached to suction? Rate? Drainage? Color? Amount? Is it infusing through pump? Rate? Amt to infuse

Pupil Size Measure before shinning light in eyes Pupils (PERRLA) Equal Round Reactive to Light Accommodation Oral cavity (use penlight) Teeth intact Mucus membranes moist Lips moist Throat Trachea midline

Posterior Thorax Inspect skin Color variations Edema Skin breakdown
Lesions, masses, scars, tattoos Assess spine Alignment Assess lung sounds Normal clear Abnormal Wheezes, crackles Identify inspiratory or expiratory Location

Anterior Thorax (Maintain Dignity of Pt)
Inspect skin Color variations Edema Skin breakdown Lesions, masses, scars, tattoos Assess skin turgor Assess lung sounds Normal clear Abnormal Wheezes, crackles Identify inspiratory or expiratory Location

Compare apical and radial pulses Location: 5th ICSMCL Normal
Assess heart sounds Compare apical and radial pulses Location: 5th ICSMCL Normal S1 & S2 Listen at apex and base of heart Abnormal: murmurs, S3, S4 Is rhythm regular or irregular Are sounds distant or muffled Telemetry monitor Continuous monitoring of rhythm 3-5 leads Attached to patients chest Ask nurse about rhythm

Abdomen Inspect skin Color variations Edema Skin breakdown
Lesions, masses, scars, tattoos Look for tubes, drains Type & location Any drainage, color, amt Look for incisions Location Any signs of infection Look for bandages Never remove a surgical dressing!

Listen for bowel sounds
Normoactive Hypoactive, Hyperactive Absent (no sounds x 5 mins) Gently palpate abdomen Is abd distended? Is abd soft or hard? Any masses, pulsations, tenderness Any facial grimacing

GU/Elimination Assess ability to urinate
Last voiding, color, odors, amount Assess ability to defecate Last bowel movement, color, consistency Palpate bladder Is it palpable Is it distended

Do they have an Indwelling catheter
Bag should hang below waist, on bed, not on side rail Color of fresh urine Amount of urine in bag Follow tube to patient, make sure there are no kinks and it is draining Tube should be over thigh and secured to thigh Assess meatus for skin breakdown

Upper Extremities (Bilateral Assessment)
Inspect skin Color variations Skin breakdown Lesions, masses, scars, tattoos Capillary refill Normal <3secs Nail polish/thick nails (skin blanching) Radial pulses Is right and left equal? Use scale to document pulse quality Regular or irregular Edema Pitting vs non-pitting

Muscle Tone Firm or flaccid Muscle Strength Equal bilateral
Range of Motion Full or Partial IV therapy Saline lock For intermittent infusions Assess catheter size & location Assess site for redness, edema, tenderness Assess for drainage Should be secure with clear tape Should be clamped Port should be attached

IV therapy (identify every bag hanging)
Primary and secondary IV therapy For continuous and secondary infusions Assess catheter size and location Assess site for redness, edema, tenderness Assess for drainage Should be secure with clear tape Tubing should be attached to patient If not it is a saline lock IV Fluids infusing Primary Assess type of fluid Assess rate Amount left to infuse in patient Secondary

Lower Extremities Take their socks off. Move Ted Hose to assess toes.
Inspect skin Color variations Skin breakdown Lesions, masses, scars, tattoos Capillary refill Normal <3secs Nail polish/thick nails (skin blanching) Pedal pulses Is right and left equal? Use scale to document pulse quality Regular or irregular Unable to feel Use Doppler and assess Tibial pulses Edema Venus Patterns

Muscle Tone Firm or flaccid Muscle Strength Equal bilateral Range of Motion Full or Partial Compression Stockings (TED Hose) Move to assess, see variations through them Only remove for bath, then put back on patient Sequential Compression Device Remove to assess, then put back on patient To prevent blood clots

Safety Last! Always Side rails up x 2
Put one side down while working, raise if you leave the side of the bed Bed/wheels locked Doesn’t move Bed low Put the bed in the lowest position possible Wash your hands

Your Turn. Round 1 Roles 1 student as patient
Saline lock L Forearm Hospital gown over scrubs 1 student for head to toe 2 students observing Round 1

Safety First! Wash hands Scan room Side rails Bed low Bed locked
Scan patient Any distress LOC-alert Respirations labored or unlabored Position HOB raised, flat, sitting straight, slumped over Mood-smiling, crying, grimacing Tubes/Lines/Drains Oxygen, NG, IV, Poles, Bags, Foley, Compression device. Wound Vac

Introductions/Vital Signs/Pain Scale
Student Name, purpose Patient Name, DOB, compare to arm band Orientation Place Day/time Side rail down, bed raised Vital Signs Temperature (97-100) Pulse/Respirations (60-100/16-24) Blood Pressure ( /60-90) O2 Sat (96-100) Recheck all abnormal readings Notify nurse & instructor Pain Scale Symptom analysis Location Quality Quantity Onset, Duration, Frequency Measures that relieve Measures that aggravate

Head and Neck Face symmetrical Speech clear
Wears glasses (on, bedside table) Hard of hearing (hearing aid) Pupil size, PERRLA Oxygen Device Type LPM Wearing? Skin breakdown NG/Feeding Tube Location Suction, rate, drainage, amt Pump, infusion rate, amt to infuse Mouth open, teeth intact, moist membranes, lips moist Trachea midline

Posterior Thorax Scan skin Color, edema, breakage
Lumps, bumps, scars, tattoos Assess spine alignment Listen to breath sounds Upper, side to side Middle, side to side Lower, side to side Laterals, side to side

Anterior Thorax Adjust gown Inspect skin Color, edema, breakage
Lumps, bumps, scars, tattoos Check skin turgor Listen to breath sounds Upper, side to side Middle, side to side Lower, side to side Laterals, side to side Heart Compare apical to radial Listen to heart sounds in 2-3 places Listen to S1 (loudest at apex) Listen to S2 (softest at apex) Any abnormal sounds Telemetry monitor attached?

Abdomen Adjust and tie gown, expose abdomen Scan skin
Color, edema, breakage Lumps, bumps, scars, tattoos Tubes or drains (type, location, drainage, color, amount Incisions (location, size. Any staples, sutures. Any redness, swelling, drainage) Bandages (type, location. Any drainage, color, amount) Listen to bowel sounds (only need 1 in 1 quadrant) Palpate abdomen (distended, soft, or hard. Masses, pulsations, tenderness. Any facial grimacing) Last voiding (color, odors, amount) Last bowel movement (color, consistency) Palpate bladder for distention Adjust gown and covers

Upper Extremities Inspect skin Color, breakage
Lumps, bumps, scars, tattoos Capillary refill Radial pulses Edema Muscle tone Muscle strength (push/pull) Range of Motion (Any restricted movements) IV Saline lock or continuous infusion Location, cath size, redness, swelling, tenderness, drainage, secure, clamped, port Type of fluid, rate, volume to be infused Side rail up, bed down

Lower Extremities Adjust covers, take socks off
Take compression device off Inspect skin Color, breakage Lumps, bumps, scars, tattoos Capillary refill Pedal pulses, can’t fill, check tibial, can’t fill get Doppler Edema Venous patterns Muscle tone Muscle strength (push/pull) Range of Motion (Any restricted movements) Put socks back on, compression device, adjust covers

Safety Last Side rails up Bed low Bed locked Wash hands

Round 2 Change Roles 1 student as patient 1 student for head to toe
Saline lock L Forearm Hospital gown over scrubs 1 student for head to toe 2 students observing

Understanding Intake and Output
8/28/ /29/16 Understanding Intake and Output According to Mr. Practice’s Intake and Output sheet, What do you notice? How does the intake and output correlate with his BUN, Cr, and albumin levels? Why isn’t he in renal failure? Let’s learn where this information comes from 8/28/16

It often begins with Breakfast
Don’t forget to bring your patient their breakfast tray and look at the contents Cereal Banana Yogurt Scrambled eggs Orange juice Coffee Biscuit

Evaluate what your patient ate before removing tray
Liquids drank Coffee Juice Solids eaten Banana ½ eggs Biscuit

Record Intake on Bedside Worksheet Check name and date.
Liquids drank Coffee ml Juice ml % of tray eaten % Document on post-clinical chart.

Output must be recorded on Bedside Worksheet
Measure the following Urine ml Emesis 0 Drains Diarrhea 0 Solid stools record each occurrence. BM 2

End of Shift I/O (Post clinical paperwork)
Graphic and I & O Record End of Shift I/O (Post clinical paperwork) Record your morning and noon vital signs Recording intake All oral intake during your shift Not just breakfast Includes all drinks all morning Record parenteral fluids & IVPB form 7A-12P Record any blood, tube feeding, irrigations. Total intake for your shift, record in 12hr total Date 8/30/2016 Hour 7A-7P 7P-7A 8 12 4 Temp Pulse Resp BP Intake Parenteral Oral 360 Blood/Plasma Piggy back Tube feeding GU irrigant 12Hr Total 24 Hr Total Output Catheter Emesis Suction Voiding 225 Drain 12 Hr Shift 24 Hr Shift Meals B 75% L ___% D ___% Weight Bowel Mov’t 2

All urine during your shift All emesis, suctioning, or drains
Graphic and I & O Record Date 8/30/2016 Hour 7A-7P 7P-7A 8 12 4 Temp Pulse Resp BP Intake Parenteral Oral 360 Blood/Plasma Piggy back Tube feeding GU irrigant 12Hr Total 24 Hr Total Output Catheter Emesis Suction Voiding 225 Drain 12 Hr Shift 24 Hr Shift Meals B 75% L ___% D ___% Weight Bowel Mov’t 2 Recording output All urine during your shift All emesis, suctioning, or drains Total output, record in 12hr total Record % of meals, current weight, and # of BMs

Hygiene How to cover the IV site for showering.

Checking the patient chart
New orders New lab results Times and/or Changes to medication administration from your preclinical day Vital sign ranges (snapshot) Home medications (navigator) Braden Scale (navigator) Do you agree with the staff? Check the patient’s chart after you finish your assessment and then several times during your shift for changes.

Assignment: Post-Clinical Documentation
A. Document the vital signs and assessment they did on their mock patient. B. Read Mr. Practice’s H&P to incorporate illness, home meds, and psychosocial information.

Head to Toe Assessment.

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Head to Toe Assessment.

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