Head To Toe

Front 1

Interpret Vital Signs

Back 1

NORMAL PARAMETERS:
Temperature: 35 to 38.5 C (96.4 to 99.1 F).Older adult 36C/97F
Pulse: 50-90 beats per minute
Respiration: 10-20 breaths per minute
Blood Pressure: 120/80 mm Hg
Oxygen saturation: 97 to 98%

Front 2

Hand Hygiene

Back 2

Before & after each direct patient contact

After removing gloves

Front 3

Gloves

Back 3

When in contact with bodily fluids

Open wounds

Contaminated Equipment

Front 4

Introduce Yourself!

Back 4

My name
My title
What I'm doing here: "I'm hoping to do a basic Heat to Toe assessment of you this morning. How are you?"

Front 5

ID your patient

Back 5

Ask Name
Date of Birth
Check vs bracelet

Front 6

Assess LOC

Back 6

Ask pt
-location & date
-reason for hospital stay
-current event

Front 7

Assess for Pain

Back 7

Ask pt about pain or discomfort
If pain, do RPQRST

Front 8

Perform Pulmonary Assessment - RAISE THAT BED!

Back 8

"Please take deep breaths through your mouth for me"

Inspect respiratory pattern for labored breathing

Auscultate breath sounds:

Posterior/Lateral: 8/2 = 10

Anterior: 4-6

"Breath sounds were clear. I didn't hear any adventitious sounds."

Front 9

Perform Cardiac Assessment

Back 9

Auscultate Apical impulse site. If you cannot find it between 4th & 5th intercostal. Ask patient to exhale & hold their breath to locate pulsation. You can also roll person to the midleft.

"S1, S2 have a normal rhythm & rate. No murmurs or rubs present."

Front 10

What's the order of assessment for the Abdomen?

Back 10

Inspect: For countour, lesions, scars.
Auscultate: Over all 4 quadrants
Percuss: Over all 4 quadrants
Palpate: Lightly over all 4 quadrants

Front 11

Perform Abdominal Assessment

Back 11

Inspect abdomen for distension. "Abdomen is flat/round. Belly button looks mid-line. No masses or abnormalities."

Before you begin auscultating tell your patient: "I'm going to listen over your abdomen. I'm going to expose your belly, but keep the rest of your body covered."

Auscultate for bowel sounds x 4 quadrants. Start at Right Lower Quadrant: "I heard a sound. I'm moving on. I heard bowel sounds x 4."

Palpate abdomen for tenderness, firmness/softeness

Front 12

While performing Abdominal Assmt, what to do if you don't hear a bowel sound?

Back 12

Bowel sounds should sound high pitched, gurgling & irregular. Listen for 30 sec at each quadrant for a 5 minutes total if no sounds are present.

Front 13

Percuss Abdomen

Back 13

Percuss in the 4 quadrants following the pattern of auscultation.

4 Triangles.

"I hear tympany sounds & dull over the liver"

Front 14

Palpate Abdomen

Back 14

Before you begin tell your patient: "Please tell me if you experience any pain or tenderness when I touch you."

Palpate lightly over all 4 quadrants for tenderness, masses (palpate in 2-3 places/quad). Begin at RLQ.

"No masses, lesions or tenderness"

Front 15

Asses upper extremities - SKIN

Back 15

Inspect skin: Touch skin & assess for temperature, moles, bruises or scratches.

"Your skin looks normal in color & is warm to the touch. Any rashes or moles you are concerned with?"

Front 16

Asses upper extremities - PULSE

Back 16

Check radial pulse bilaterally for rate, rhythm, strength and symmetry.

"The rhythm is even. The pulse is "weak: 1 plus pulse," "normal: 2 plus pulse", "full, bounding: 3 plus pulse"

Front 17

Asses upper extremities - VASCULAR

Back 17

Check hands & fingers

Do capillary refill on fingers.

"Normal bilateral capillary refill at less than 2 seconds"

Front 18

Asses upper extremities - NEUROMUSCULAR

Back 18

Ask patient to squeeze your two fingers bilaterally.

NOTE: A weak grip is associated with UMN/LMN disorders or local problems: arthritis, carpal tunnel syndrome

Front 19

Asses lower extremities - SKIN

Back 19

Inspect skin: Touch skin & assess for temperature, edema, moles, bruises or scratches.

Front 20

Asses lower extremities - PULSE

Back 20

Assess pedal pulses (Dorsalis Pedis, Posterior Tibial) for strength and symmetry.

"The rhythm is even. The pulse is "weak: 1 plus pulse," "normal: 2 plus pulse", "full, bounding: 3 plus pulse"

Front 21

Asses lower extremities - NEUROMUSCULAR

Back 21

Plantar flexion and extension against your resistance

Front 22

Tell your patient your findings

Back 22

"Everything was normal"

OR

"I have found the following _____. It was an unexpected finding. I will let the doctor know so she can come & talk to you about it."

Front 23

Environmental Safety - Precautions

Back 23

Keep bed in low position - LOWER BED!
Keep bed brakes on - PUSH BED TO VERIFY IT'S LOCKED!
Keep upper side rail in UP position
Orient patient to call light. "PRESS THE RED LIGHT IF YOU NEED ME"
Keep environment cleared of hazards: Clean spills & remove debris from floor
Visualize emergency equipment is present & functional - CHECK FOR SUCTION, PRESSURE BAG, OXYGEN, BLOOD PRESSURE CUFF."

Front 24

Contaminated Equipment

Back 24

Inspect appropriate disposal containers (sharps, soiled linens)

Dispose of contaminated items in designated containers.

Front 25

Use SBAR Communication

Back 25

Situation
Background
Assessment
Recommendation