Download - Head to Toe Assessment
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Head to Toe Assessment
• https://www.youtube.com/watch?v=cP4zgb9H3Cg
• Generalized patient assessment• Work from the head down– Know normal = identify abnormal
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Palpate Head and Neck
• Checking for lumps and bumps any lesions or tenderness
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Check the ears
• Use an Otoscope
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Check Nose and Mouth
• Is there redness, swelling, drainage, abnormal bumps, color, lesions
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Pupil Check
• PERRLA (pupils, equal, round, react to light, accommodate)– Accommodate – ability of eyes to focus
on objects that are close up and faraway
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Neck Veins
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Heart Sounds
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Auscultation of Breath Sounds
• Normal• Crackles- light crackling, bubbling• Rhonchi- coarse crackles• Wheezes- creaking, whistling, high
pitched
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Pulse Checks
• Strength of pulse– 0 = absent– 1 = barely palpable– 2 = easily palpable– 3 = full– 4 = Bounding pulse
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Capillary Refill
• < 3 second Blood return– The rate at which blood refills empty
capillaries– Indication of dehydration and peripheral
perfusion
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Reflexes
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Reflexes
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Reflexes
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Homan’s Sign
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Skin Turgor
• 1-3 second return• Used to assess the degree of fluid loss
or dehydration
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Skin Breakdown Check
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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
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Peripheral Edema
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Bowel Sounds
• Absent, Hyperactive, Hypoactive, Normal
• To state absent you must listen for 5 min in each quadrant
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Palpate the abdomen
• To be done after listening to bowel sounds
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Pain
• Location, duration, sensation, intensity• What makes it worse or better
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Baby Reflexes