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Head To Toe Assessment

This document provides guidelines for conducting a physical assessment of a patient by body system. It lists key areas to examine for the neurological/psychosocial, respiratory, cardiovascular, gastrointestinal, and integumentary systems. Examiners are instructed to assess things like orientation, motor function, breath sounds, pulse, bowel sounds, skin integrity, and urine output. Guidance is also given on inspecting tubes, lines, wounds, and surgical sites. The thorough assessment covers the patient's overall condition and functioning of major organ systems.

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sandaman2225
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696 views3 pages

Head To Toe Assessment

This document provides guidelines for conducting a physical assessment of a patient by body system. It lists key areas to examine for the neurological/psychosocial, respiratory, cardiovascular, gastrointestinal, and integumentary systems. Examiners are instructed to assess things like orientation, motor function, breath sounds, pulse, bowel sounds, skin integrity, and urine output. Guidance is also given on inspecting tubes, lines, wounds, and surgical sites. The thorough assessment covers the patient's overall condition and functioning of major organ systems.

Uploaded by

sandaman2225
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Guidelines Documentation Physical Assessment

NEU ROLOG ICAL/PSYCHOSOCIAL Ability to communicate: . Language, barriers mechanical ' Ilearingdeficits/aids - Orientatedto person,place & tirne (x 3) - Pupils - reaction& size - Motor & sensorytesting (.prn) - Motor {unction & strength (pm) response to analgesia management, - Pain - presence/absence, - Patient/familyresponse to illness - Visitor interaction Gait (steadyor tursteady) devices(walker, splints,prosthesis), - l.evel of activity - includeassistive

RESPIRATORY
Spontaneous or via tracheotomy Oxygen delivery system,oxygensaturation Rate, rhytirm, effort

Chest: Air entry: equal throughout, decreased to bases? Breath sounds- no adventitioussounds.crackles.wheezes Expansion symmetry Position of trachea Cough - productiveor non productive

Suctioning: - Oral, nasal,trach - Amount, description Chest Tubes: - Drainage system (Pleurevac) - Location, suctioniunderwater seal - Fluctuation,bubbling - Drainage - amount & colour; dressing Surgical Incisions (relating to thorax): colour - Location, appearance, drainage, - Sutures,dressings

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CARDIOVASCULAR - regular or irregular Pulse BloodPressure: dry clammy, Skin colour- mottled,pink, pale,cyanotic, - cool,cold,warm,hot,diaphoretic Skintemperature route Bodytemperature - febrile,afebrile, or < 3 seconds refill: > 3 seconds Capillary
PeripheralPulses:Presentor Doppler - DP x Edema: +), - Location, Description(pitting - Dependent,peripheral,total bodY PT x

vascath (Dialysis) Lines: cvAD, PICC, Peripheral,IVAD (portacath)o - Solutionsinfused,rate,use of infusion devices swelling or infiltration) - Infusion sites- condition (redness, - dressing

GASTROINTESTINAL
NPO or Diet - type, tolerance; o TPN - rate o External feeds- tYPeand rate Type of Tube: bore- small or large,Gastricor J tube NG - to straight drainageor low gomco (suction) volumes Check placementor resiCual Nauseaor vomiting?

then Feel Abdominatassessment:-+ Look,Listen,


Inspect Auscultate Percuss etc' obesity,herniations, scars, Skin, distention, BS -+ hypo: everyminute;normal: every 15 - 20 sec;hyper: about every -i sec Tympany - Air-filled. bowels Dullness - solirl, ofgan; Flatness- Muscle,bone Resonance - Lungs; pain, always rigidity. When assessing tenderness, Pulsatiorl masses, work from areaof leastpain towards areaof most pain'

palpate

- Bowel Sound- presentin all quadrants;absent;hyperactive - Flatus/belching of drainage - site & type, amount,colour, consistency - Drains/tubes colour drainage, - Surgical incisions- location,appearance, - Suturesidressings Bowel movements: date of late BM? Formed ? Loose ? lncontinent? etc. - Route - ileostomy,colostomY,

T6

G EN I T O U RIN A R Y Urine output: Route- spontaneous, Foleycatheter, urinarydiversion Description colour,consistency, odour - amount,

Dialysis: Method- peritoneal, hemodialysis Cathetersite/description

SurgicalIncisionsG/t GU system) (scrotum, penis, Presence pain,swelling of drainage- tenderness, labia)

SKIN ASSESSMENT Skin integrity- intact,wounds, areas, bruising breakdown or reddened Location Dressing: Therapeutic Bed (relating Surgical incisions to circulation)

t7

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