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Head to Toe

Assessment

Physical assessment tools

  • nurse examines body structures
  • observes clients physical appearance, mood, mental status, behaviors, ability to interact
  • Systems method-assessing each body system separately.
  • Head to toe method-examine beginning top of head working downward

Inspection

  • nurse uses senses of vision, smell, hearing
  • includes changes in skin color, temp
  • observing wound for signs of healing, or infection
  • noting color, size location, texture, symmetry, odors and sounds
  • expose area being inspected while draping rest of client. *look before touching. *use adequate lighting. *provide warm room for exam

Neurological Assessment

  • Orientation
  • Speech
  • Pupils
  • Glasgow Coma Scale
  • Muscle movement/Strength

Skin Integrity

  • Color
  • Temperature
  • Abnormalities:

Ecchymosis/bruising

Abrasions, punctures

Ulcers

Incision

Scars

Cardiovascular

Assessment

  • Skin/turgor
  • Capillary Refill
  • Apical Pulse/Rhythm
  • Heart Sounds
  • Peripheral Pulses
  • Edema
  • ECG Assessment (if applicable)

Respiratory

Assessment

  • Pulse oximetry
  • Cough
  • Oxygen
  • Respiratory Effort/ Rhythm
  • Breath sounds

http://www.wilkes.med.ucla.edu/lungintro.htm

Gastrointestinal

Assessment

  • Oral Mucosa
  • Abdomen
  • Bowel Movements
  • Last BM
  • Nutritional Intake
  • Bowel Sounds
  • Tubes
  • Tube Feeding
  • Stoma
  • Nausea/Vomiting

Genitourinary Assessment

  • Reproductive Organs
  • Urination
  • Urine Amount/Color/Characteristics
  • Urostomy
  • Urinary Catheter

http://www.easyauscultation.com/heart-sounds.aspx

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