Complete Guide Professional Nursing I (NUR 3805) Head To Toe Assessment Guide

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Head to Toe Assessment  Perform Hand Hygiene and Provide Privacy to patient  PRESENT YOURSELF -Hello, my name is Randy Chavez and I need to perform a head to toe assessment on you. Is that... ok with you?  LOOK AT PATIENT’S ARM BAND - (This will help you to have the right patient)-  -Ask Patient all personal information in the Band to help you check their NEUROSTATUS -Can you tell me where we at? -Can you tell me what we are doing today? -Can you tell me who is the President of the U.S? (If Patient responds to all questions correctly, you can say that patient is ORIENTED AND ALERT x 3)  VITAL SIGNS -Heart rate (60-100 bpm) -Blood Pressure (119/79) -Temperature (98.6) -Oxygen Saturation (75-100 mm of mercury) -Respiratory Rate (12-20 Breaths per minute) -Patient Pain Rate  Ask Patient: -Are you having any pain on a scale of 0-10, zero for the less pain and 10 for the worse pain you have ever had?  COLLECT HEIGHT, WEIGHT, BMI BMI: -less than 18.5 (underweight) -more than 30 (obese) WHY WE ASK ALL THESE QUESTIONS?... -Why are we asking all these questions and taking vital signs to the patient? A/ The meaning of all done above is to collect all information from the patient and check for: -Patient’s Emotional Status: (are they calmed, agitated, drowsy?), in fact just to see what’s going on with the patients. -To check if they look their stated age. -To check if the skin color matches their ethnicity? -To check if they understand all the questions and see if they can hear well, or if is a delay on their responses. -To notice while talking any masses, lesions, amputations, skin sweaty. -To check if their hygiene is good? -To check if their posture is good? -To check for any abnormal smell. Then move on to HEAD  First, Inspect the head. 1 Downloaded by John Mixer (john.mixer9@gmail.com) lOMoARcPSD|2843306 HEAD TO TOE ASSESSMENT GUIDE  Look for Skin Color o If is nice and pink?  Check that head is in size with the body  Check for any abnormal or twitching of the face that Patient cannot control by himself or does involuntary  Check that face is symmetrical (like bell’s palsy and people with Stroke)  Look for Eyes on the Same Level  Look at facial Expressions and check CRANIAL NERVE # VII (7) FACIAL, performing a facial nerve check. HOW TO CHECK THE NERVE #7 -ASK patient: Close your eyes tightly and open them up. -ASK patient: Smile for me -ASK patient: Round for me -ASK patient: Pop out your cheeks  Palpate the HEAD. (Cranium) --Wearing gloves: -Check for any masses, indentations, or infestations -Check for Skin Breakdown -Check inside the Hair (for lies) or baldness (alopecia)  Find Temporal Artery and feel them bilaterally.  While in that area, Check for CRNIAL NERVE # V (5) TRIGEMINAL. (responsible for mastication and some movements) HOW TO CHECK THE NERVE #5 -ASK patient: to bite down hard and feel the temporal muscle and mystical muscle. -ASK patient: Try to open mouth over resistance.  Inspect and Palpate Sinuses by putting pressure -ASK the patient: Do you feel any pain when I press here? Then move to the EYES  Check the eyelids, pupils, sclera, conjunctiva, and iris.  Check for EYE LIDS Swollenness.  Check for Sclera (should be white). If yellow, suspect Jaundice 2 Downloaded by John Mixer (john.mixer9@gmail.com) lOMoARcPSD|2843306 HEAD TO TOE ASSESSMENT GUIDE  Check Conjunctiva -ASK patient: To look up. (Should be nice and pink)  Check EYE SOCCERS. -Are they equal? -Are there any strabismus?  Check Pupils -Are there any Anisocoric? (one pupil bigger than the other one)  Check for Pupil Measurement. -Normal Measurement should be 3-5 mm  While there, Check for CRANIAL NERVE #3 (OCULOMOTOR), #4 (TROCHLEAR), #6 (ABDUCENS) HOW TO CHECK CRANIAL NERVES #3, #4, #6 -Get a penlight and move as 6 cardinal fields of Gaze (picture below). -Look for any involuntary shaking of the eyes while following the penlight.  Check how reactive Pupils are to light. -Pupils should constrict the same on both eyes when presenting light. -If pupil normal measurement is 3 mm, should constrict to 1 mm  Check for Pupil Accommodation -ASK patient: to stare at your penlight and move it towards the midline of both eyes. -Eyes should cross and pupils should constrict When Documenting this exam, you should say that PUPILS are: P- pupils are E- equal R- round and reactive to L- light A-and accommodate Then move to EARS  Inspect ears for abnormalities, redness, drainage Ask patient: Are you having any pain?  Check for Tophi. 3 Downloaded by John Mixer (john.mixer9@gmail.com) lOMoARcPSD|2843306 HEAD TO TOE ASSE [Show More]

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