Monday, 21 May 2012

Head to Toe Assessment

It is possible to do head to toe assessment in less than 5 minutes without missing anything along the way. Start from the head and end at the toes and you'll be sure you don't miss anything.

1. level of consciousness (LOC) : is this person alert? drowsy? lethargic?
2. Head
  • Head: check for any abrasions, lice, bumps, etc
  • eyes: check for PERRLA (Pupils Equal and Round and Reactive to Light and Accomodation)
  • nose
  • mouth
check inside the mouth for any mouth sores 
3. Neck  
  • lymph node ( is it swollen?)
  • jugular vein distention ( JVD)
4.  Arms
  • Cap refill ( fingernails; does it refill in 3 secs. or less?)
  • hand grip 
  • radial pulse
  • ROM, strength
5. chest
  • respiration (shallow?regular?irregular? normal respiratory rate: 12-20 breaths per min)
  • skin turgor( does the skin tent up? to assess patient's hydration status)
  • apical pulse( left mid clavicular, 5th intercostal space.)
  • lung sounds
6. abdomen
  • abdominal exam ( bowel sound) : inspect, auscultate, palate.
  • BM
  • Pain
7. GU
  • bladder distention
8. Legs 
  • pedal pulse (check dorsalis pedis)
  • edema
  • Homan's sign ( ask patient to dorsiflex their feet while you hold their calf. If sharp pain is present, there's a possible deep vein thrombosis)
  • cap refill . ( for the toenails)
  •  ROM

* Throughout the assessment process, inspect the skin.

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