Head To Toe Pbsu

Front 1

KIWISPLS
8 items

Back 1

a. Knock on door
b. Introduce self
c. Wash hands and put on gloves
d. Identify patient using 2 sources (ask name, ID band)
e. State your service
f. Provide privacy
g. Check locks on bed
h. Gather needed supplies

Front 2

General Survey
5 items

Back 2

a. Overall hygiene, grooming and appearance
b. Signs of distress – e.g. guarding, grimacing
c. Gait and posture – sitting, standing, walking
d. Obvious signs of health or illness – e.g. skin color, breathing pattern
e. Overall condition of skin – color, temperature, moistness, lesions

Front 3

Assess mental status
5 items

Back 3

a. Determine patient’s orientation to time, place and person
b. Note client’s affect and mood
c. Note appropriateness of verbal responses – relevance and organization of thoughts
d. Speech quality (amount and pace) and quantity (loudness, clarity and inflection)
e. Vital Signs – Temperature, pulse, respirations, blood pressure, pulse oximetry and pain level using 0 -10 scale

Front 4

Head
2 items

Back 4

a. Size and shape of skull
b. Symmetry of facial features and facial movements

Front 5

Hair and scalp
6 items

Back 5

a. Texture and oiliness
b. Thickness or thinness
c. Growth pattern over scalp
d. Infections, lesions or
e. Assess behind ears and along hairline at neck
f. Note presence and amount of body hair

Front 6

Assess the Ears
4 items

Back 6

a. Auricle for skin integrity, color, symmetry of size and position
b. External canal for cerumen, drainage, lesions
c. Response to normal voice tones – Whisper test, hearing aids
d. Have patient turn head to side to evaluate ROM

Front 7

Assess the Face
3 items

Back 7

a. Palpate temporal pulses
b. Palpate frontal and maxillary sinuses
c. Note edema or hollowness around the eyes

Front 8

Assess the Eyes
5 items

Back 8

a. Eyebrows movement and hair distribution
b. Eyelids – ability to blink
c. Conjunctive – color, discharge or lesions
d. Pupils – color, shape, symmetry, reaction to light, accommodation to distance
e. Six ocular movements to determine alignment and coordination

Front 9

Assess the nose
6 items

Back 9

a. Have patient put head back (checks ROM)
b. Inspect for deviations in shape, size and color
c. Flaring or discharge from nares
d. Patency of both nares
e. Inspect nasal cavities with penlight.
f. Inspect septum. Observe for redness, swelling, growths and discharge

Front 10

Assess the Mouth

Back 10

a. Inner and outer lips, gums and mucosa for color, moisture and lesions
b Note presence of dentures, bridges and own teeth.
c. Hard and soft palates for color, shape, texture and bony prominences
d. Tonsils for absence or presence.. Note color, size and any drainage
e. Tongue for moisture, lesions, position (midline)

Front 11

Assess the Neck
4 items

Back 11

a. Rotate head ear to shoulder (ROM)
b. Neck muscles for swelling or masses; enlarged lymph nodes
c. Palpate trachea for lateral deviation and enlarged thyroid gland
d. Assess carotid arteries one at a time

Front 12

Assess the Thorax
2 items

Back 12

a. Turgor
b. Symmetry from lateral and posterior views

Front 13

Assess Breasts and Axillae

Back 13

a. Teach client SBE technique (perform on mannequin, not patient)
b. Inspect breast size, contour, symmetry and shape
c. Inspect skin for localizes discoloration, dimpling, retraction or edema
d. Inspect nipples and areola for shape, symmetry, color surface characteristics, masses, discharge or lesions.
e. Palpate breast tissue for masses and tenderness

Front 14

Assess the Heart

Back 14

a. Auscultate heart in all 4 anatomic sites: aortic, pulmonic, tricuspid and mitral) APETME ( Also epigastric area. Erbs optional) )
b. State normal range of heartbeats is 60-100 beats per minute
c. State S1 heard over tricuspid and mitral; S2 heard over pulmonic and aortic

Front 15

Assess the lungs
4 items

Back 15

a. Breathing pattern (rate, rhythm, depth, effort) State normal respiratory rate 12-20 breaths per minute.
b. Auscultate posteriorly and anteriorly
c. Posteriorly inspect spinal alignment for deformities and lateral deviation
d. Have client take slow, deep breaths through their mouth. Listen at each point during inspiration and expiration. Note any adventitious sounds

Front 16

Assess the Abdomen
9 items

Back 16

a. Any dietary restriction; usual eating pattern
b. Last bowel movement (color, consistency, bleeding, pain) usual bowel habits
c. Inspect contour and symmetry
d. Auscultate for bowel sounds in all 4 quadrants
e. State listen for 4 minutes in each quadrant to determine absence of bowel sounds
f. Light palpation for tenderness and guarding if no complaints of pain
g. Ask about usual voiding pattern. Ask if any frequency, hesitancy, urgency, odor, unusual color.
h. Palpate bladder above symphysis pubis for distention
i. Assess femoral pulse

Front 17

Asses Genital Area

Back 17

a. Perineal area for odor, discharge, lesions
b. Note if indwelling catheter present
c. Females: Ask when was LMP. Males: ask if they perform self-testicular exams
d. Note any abnormalities of genitalia

Front 18

Assess arms

Back 18

a. Inspect nails noting shape, bed color, angle, any clubbing
b. Inspect surrounding tissue
c. Perform capillary refill (3 seconds or less)
d. Palpate brachial, radial and ulnar pulses bilaterally
e. Assess musculoskeletal system
1. compare muscle strength of one side to the other
2. note contractures or tremors
3. Inspect joints for swelling and tenderness, smoothness of movement, crepitus, and nodules
4. Demonstrate ROM on self (shoulders, elbow, wrist, fingers)

Front 19

Assess Legs

Back 19

a. Inspect nails noting shape, bed color, angle, any clubbing
b. Inspect surrounding tissue
c. Perform capillary refill (3 seconds or less)
d. Palpate pulses (popliteal, dorsalis pedis and posterior tibial)
e. Assess calves for pain, swelling, redness, tenderness (may do Homan’s sign if none present)
e. Assess musculoskeletal system
1. compare muscle strength of one side to the other
2. note contractures or tremors
3. Inspect joints for swelling and tenderness, smoothness of movement, crepitus, and nodules
4. Demonstrate ROM on self (hip, knee, ankle)

Front 20

Turn patient on side and assess lower back and anus

Back 20

a. Inspect anus and surrounding tissue for color, integrity and lesions
b. Note presence of edema –location, temperature, degree of pitting