head to toe assessment

Head to Toe Assessment

• https://www.youtube.com/watch?v=cP4zgb9H3Cg

• Generalized patient assessment• Work from the head down– Know normal = identify abnormal

Palpate Head and Neck

• Checking for lumps and bumps any lesions or tenderness

Check the ears

• Use an Otoscope

Check Nose and Mouth

• Is there redness, swelling, drainage, abnormal bumps, color, lesions

Pupil Check

• PERRLA (pupils, equal, round, react to light, accommodate)– Accommodate – ability of eyes to focus

on objects that are close up and faraway

Neck Veins

Heart Sounds

Auscultation of Breath Sounds

• Normal• Crackles- light crackling, bubbling• Rhonchi- coarse crackles• Wheezes- creaking, whistling, high

pitched

Pulse Checks

• Strength of pulse– 0 = absent– 1 = barely palpable– 2 = easily palpable– 3 = full– 4 = Bounding pulse

Capillary Refill

• < 3 second Blood return– The rate at which blood refills empty

capillaries– Indication of dehydration and peripheral

perfusion

Reflexes

Reflexes

Reflexes

Homan’s Sign

Skin Turgor

• 1-3 second return• Used to assess the degree of fluid loss

or dehydration

Skin Breakdown Check

Peripheral Edema

• Caused by fluid in the tissues tends to be dependent– 0 no edema– +1 Trace indentation rapid return to normal– +2 Mild indentation rebounds in a few

seconds– +3 Moderate, 10-20 second to return to

normal– +4 Severe, >30 second to return to normal

Peripheral Edema

Bowel Sounds

• Absent, Hyperactive, Hypoactive, Normal

• To state absent you must listen for 5 min in each quadrant

Palpate the abdomen

• To be done after listening to bowel sounds

Pain

• Location, duration, sensation, intensity• What makes it worse or better

Baby Reflexes

• Assessment Song