Head to Toe

  • Review Doctor’s Orders – transmission-based precautions, mobility restrictions, type of transfer, patient name, MRN, DoB, allergies
  • Hand Hygiene
  • Introduce self, explain procedure, obtain consent
  • Confirm patient – name, DoB, allergies, MRN. Confirm via worksheet and armband
  • Environmental assessment
  • Raise bed – patient in semi fowlers
  • General look over – appear in pain, colour, anything look wrong? (symmetry, face drooping)
  • Check for A&O x3 – person, place, and time
  • P – provoke/palliates - what causes the pain, what makes it better or worse?

Q – quality – how does the pain feel? (sharp, dull, burning, stabbing)

R – region/radiation - where is the pain located, does it move or is it confined?

S – severe – scale 1-10

T – Time – when did it start? Was the onset fast or slow, how long has it lasted, constant or intermittent?

  • Vitals & capillary refill
  • PERRLA – check baseline size of pupils, check for symmetry, come with light from side into one eye, note pupil dilation, do it again watching other eye. Make sure dilation is bilateral. Do it with light on the other eye. Hold the pen in front and bring closer to eyes and nose, noting accommodation with eyes and pupils.
  • Ask if they have been experiencing any chest pain, cough, or Shortness of breath (Dyspnea)
  • Cardio assessment – Ape to man, apical pulse at mitral

Aortic – 2nd intercostal, right of the sternal border. Pulmonic – 2nd intercostal, left of sternal border. Erb’s point – 3rd intercostal space at the sternal border. Tricuspid – 4th intercostal left of sternal border. Mitral – 5th intercostal midclavicular. (maximum impulse)

Temporal (temple), carotid, apical (with cardiac), brachial, radial, femoral (groin), popliteal (behind knee), posterior tibial (above ankle, proximal), and dorsalis pedis pulse (top of foot)

No cyanosis, no pallor. BP 90/60-140/90, radial, brachial and pedal pulses equal and present bilaterally. HR 60-100 BPM in a regular rhythm. Cap refill < 3 seconds

APETM sequence all heart sounds normal.

S2>S1 aortic, pulmonic valves

S1=S2 Erb’s point

S1>S2 triscuspid and mitral valves

  • Respiratory assessment - apex of the lung which is right above the clavicle

Then move to the 2nd intercostal space to assess the right and left upper lobes.

At the 4th intercostal space you will be assessing the right middle lobe and the left upper lobe.

  • Then midaxillary (below armpit) at the 6th intercostal space you will be assessing the right and left lower lobes.

Alert, relaxed,  No cyanosis or pallor. Breathing is effortless. AP:transverse ratio 1:2. RR = 12-20,02 sat > 95% on R/A, No SOB, . no tenderness or masses. Good A/E  breath sounds clear bilaterally from apex to bases . No adventitious breath sounds.

  • Abdomen assessment – inspect for distention, symmetry with pen light, auscultate RLQ clockwise, light palpation – Ask when they had their last bowel movement, what was the colour, consistency, amount. Note if they have incontinent products or an ostomy bag. Ask if there are any abnormal issues with flatus, nausea/vomiting, dysphasia (difficulty swallowing), how their oral health is, appetite, typical diet, and note if they have dentures.

Last BM < 3 days. No change in appetite, no N&V No diarrhea or constipation.

Abdomen is symmetrical, normal contour, no scars, no straie.No masses.

BS present x 4 quadrants, no bruits.

No abdominal distention noted, abdomen soft. No abdominal pain,tenderness or masses

***Note any ostomy or dressings

  • Assess last urine void, colour, clarity, frequency and note if they have any devices, catheters or incontinent products
  • General assessment of skin and limbs – note skin perfusion (colour, dry, intact, test for turgor (dehydration pinch test), wounds, pressure points, dressings, IV sites, peripheral edema, pitting edema, grip strength, pedal strength (push and lift against holding), ROM, note mobility aid.

Limbs symmetrical, even muscle tone bilaterally.

Gait steady, hand grips strong, leg strength equal bilaterally, good coordination.

Denies any MSK pain.

  • Patient sit forward, assess posterior skin and listen to posterior lung sounds
  • Leave client safe, clean, and comfortable
  • Hand hygiene
  • Document