University:
University of Alberta
Course:
NURS 125 | Nursing Practice - Health Assessment
Academic year:

2024
Views:

270

Pages:

2
Author:

Ali O

Chapter 32: Head to Toe Assessment Subjective Data Collection · Demographic data · health history (allergies, medications, family health, etc. ) · assessment of risk factors A - assessment · areas of health promotion D - diagnosis · latershaps P - planning · growth and development I - implementing · review of systems E - evaluation · psychosocial history · activities of daily living Common Allergies: · Latex · Penicillin · Sulpha · peanuts · milk · pollen, mold · pets · wasp stings Physical Examination · introduce yourself, wash hands etc. · vital signs ↳ height, weight, temperature, pulse, respirations, O2 saturation, BP · Note any immediate red flags · Examination techniques: inspection, palpation, percussion, auscultation · can do a broad or more focused assessment as needed Head to Toe Assessment · skin and hair throughout assessment · LOC (CNS assessment) . HNEENT ↳ head and neck (cranial nerves) ↳ eyes and ears ↳ face (sinuses), nose, mouth, and throat · Thorax and breast exam · Heart and peripheral vascular (extremeties) · Abdominal · Genitourinary and testicular exam · Musculoskeletal General Survey · initial observation · "looks good" vs "looks bad" · fever, chills, diaphoresis, flushed etc · fatigue, weakness · pain · activity level · posture · hygiene · LOC · ABC's · safety · sleeping? Always Consider ABC's!!! · Airway · Breathing · Circulation · if compromised more to urgent assessment Head to Toe Order 1. Vital signs · temperature: 36.5-37.5°C · pulse: 60-100 bpm · respiration: 12-20 breaths/min · BP: Systolic 100-120, diastolic 60-80 mmHg 2. General Survey · inspect patient, ask questions etc. 3. Skin · inspect and palpate 4. HNEENT + Neuro · inspect and palpate as needed · LOC · cranial nerve basics ↳ Cardinal movements ↳ pupillary light response ↳ swallowing... etc. · ask about pain, appetite, ROM etc. 5. Thorax and Lungs · respiratory effort · respiratory rate, effort, depth, symmetry · SOB, 02 saturation, oxygen requirements · Adventitia: Wheezing or crackles · cough, secretions · pain · x-ray 6. Breast Exam · if needed 7. Heart and Peripheral Vascular · heart rate, rhythm, murmurs, extra sounds · full cardiac exam · complete extremeties assessment ↳ pulses ↳ capillary refill ↳ edema, skin colour, hair growth 8. Abdomen · inspection, auscultation, percussion, palpation · complete abdominal exam · question about: bowel movement, urination, appetite, eating habits 9. Genitourinary · inspect and palpate as needed · urine amount, colour, issues voiding 10. Musculoskeletal · inspect and palpate · swelling, stiffness, pain · mobility, ROM · Gait, balance, coordination · weakness, tremors · joint mobility, muscle strength and tone · CSMT!!! ↳ circulation, sensation, movement, temperature