Head to Toe Shift Assessment

UNIVERSITY OF ALBERTA FACULTY OF NURSING Instructor: VJ Gibbins RN MS PhD Head to Toe / Systems Assessment BOLDED DESCRIPTORS ARE NORMAL / EXPECTED FINDINGS Central Nervous System Assess for level of consciousness ●​ Alert, oriented, follows commands, moves spontaneously, drowsy, confused, comatose, restless, lethargic, Glasgow Coma Scale ____ (out of 15) Glasgow Coma Scale Eye Opening​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Verbal Response​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Motor Response ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ ​ Spontaneously​ ​ ​ ​ To Speech​ ​ ​ To Pain​ ​ ​ ​ None​ ​ ​ Oriented to (Person,Place,Time)​ ​ Confused​ ​ ​ Inappropriate words​ ​ Incomprehensible​​ ​ None​ ​ ​ Obeys Commands​ ​ ​ Localizes to Pain​​ ​ Withdraws from Pain​ ​ Flexion/Decorticate​ ​ Extension/Decerebrate ​ ​ None​ ​ ​ 4​ 3 2 1 5 4 3​ 2 1 6 5 4 3 2 1 Assess Mood/Affect: ●​ Cooperative, communicative, pleasant, flat affect, hostile, labile, withdrawn, irritable, anxious / apprehensive, agitated, identify reassurance or support needed Assess Neurological VS when appropriate (pupil reactivity / size, hand grasps, hand and foot strength on flexion and extension) ●​ post op neuro surgery, ●​ closed head injury, ●​ concussion, ●​ fresh stroke patient ●​ any time level of consciousness is altered Assess Level of Sedation (post op or Epidural) ●​ skin dermatomes Pain Assessment – This is a PRIORITY ASSESSMENT. Assess patient’s desired or tolerable level of pain on scale of 1-10 (or appropriate pain scale for age / LOC / Developmental Level Assess current level of pain and location Assess contributing factors – What brings it on? What makes it worse? Assess alleviating factors – What makes it better? Assess description of pain ●​ Absence or acceptable level of pain or discomfort as indicated or reported by patient or family. Non-verbal patient shows no signs of grimacing, guarding or restlessness. ●​ Sharp, burning, dull, radiating, pressure, uncomfortable, “Feels like there is an elephant standing on my chest,” REMEMBER patients experiencing chest pain may not describe having pain, but pressure or discomfort! Listen for these clues to a cardiac event! ●​ Non Verbal signs: grimacing, guarding, restlessness, elevated VS readings without cause Page 1 of 4 Respiratory (VS: Respiratory Rate, Pulse Oximetry) Assess respiratory quality ●​ Quiet, regular, chest movement symmetrical, irregular, shallow, stridor, dyspnea, nasal flaring, apnea, accessory muscle use, retractions Assess air entry and breath sounds in all lobes ●​ Clear, equal bilaterally, diminished, wheezing – inspiratory and / or expiratory, absent, upper respiratory noise – often clears with a cough, course crackles, fine crackles Assess sputum ●​ Patient swallows sputum, thin, clear, copious, moderate, scant, frothy, plug, green, yellow white, tan, bloody, blood tinged, thick, tenacious, pink Assess mucous membranes ●​ Moist, pink, pale, cyanotic, dry, sticky Assess for a cough ●​ Absent, non-productive, productive, loose, dry, barking, raspy, occasional, frequent, harsh Assess oxygenation ●​ Pulse oximetry > 94% on room air (RA) ●​ If on oxygen, note O2 device and rate of flow Cardiovascular (VS: Temperature, Apical Heart Rate, Blood Pressure) Assess heart sounds ●​ Regular apical rhythm, rate within normal limits, irregular rhythm, murmur present, tachycardia, bradycardia Assess skin colour ●​ Colour is within patient’s norm - usually pink, pale, pale pink, jaundice, flushed, dusky, ruddy, mottled, sallow, cyanotic Assess skin temperature and moisture ●​ Warm and dry, hot, cool, clammy, diaphoretic, flaky Assess nail bed colour and capillary refill time – CRT ●​ Pink, CRT < 3 sec, pale pink, pale, white, dusky, cyanotic, sluggish Assess peripheral pulses ●​ Palpable bilaterally at radial, dorsalis pedis and posterior tibialis pulse points, bounding, weak, thready, Doppler needed to assess, absent Assess edema ●​ None present ●​ Location: peripheral, ocular, general, dependant, scrotal, facial, other-specify ●​ Pitting Edema grade: +1 Trace – disappears rapidly, +2 Moderate – disappears in 10-15 secs, +3 Deep – disappears in 1-2 minutes, +4 Very Deep – present after five minutes Gastrointestinal Assess for nausea and / or vomiting. This is a PRIORITY ASSESSMENT ●​ None, tolerates prescribed diet, ●​ Emesis amount, colour, and consistency – clear, yellow, brown, green, black, coffee grounds, blood tinged, red Assess abdomen ●​ Soft, non tender on palpation, firm, distended, tender, rounded, obese Assess bowel sounds ●​ Present in four quadrants, absent, hypoactive, hyperactive Assess stool – bowel routine ●​ Having BM within own normal pattern and consistency, bloody, pink, burgundy, coffee ground appearance, yellow, green, black, tan, brown, incontinent, liquid, hard, seedy, clay, mucous / mucoid, none, loose, scant, moderate, smear Assess NG Tube ●​ Placement must be verified every shift – check for institutional policy regarding preferred method. Usually air insufflation auscultated over stomach is sufficient. ●​ With Tube Feeds, gastric residuals are checked every 4 hours and noted. Check institutional policy regarding critical aspirates and return / discard of residual. Most institutions also have a flushing policy – flush with water 30cc every 4 hours, etc. Page 2 of 4 Assess NG / Drain suction ●​ Clamped, gravity, continuous, low intermittent (LIS) ●​ Note Drainage: bloody, pink, burgundy, coffee ground appearance, yellow, green, black, tan, brown, serous, serosanguinous, mucoid, purulent, copious, scant, moderate, tenacious, plugged. Genitourinary Assess voiding characteristics ●​ Able to empty bladder without dysuria, incontinent, frequency, urgency, dysuria, no void, foley catheter, condom catheter, note any incontinent products being used – attends, pads, mesh underwear, bedpan, urinal, speci-hat, ostomy, commode, etc. Be sure to pass on to the nurse if the patient has not voided on your shift. Assess urine characteristics ●​ Clear, yellow or amber, free of foul odour, concentrated, orange, brown, bloody, dilute, tea coloured, cloudy, sediment, menses present, note if urine is discoloured as a result of a medication ex. Rifampin causes urine to be orange Assess Urinary Catheters ●​ Foley / catheter patent, draining clear yellow urine freely by gravity. Note size of catheter ___french. ●​ Assess site of catheter: No redness, discharge or pain noted by patient at catheter site. No bladder distension. ●​ Note if your patient is ordered for post-void residual catheterizations or bladder scans. Integumentary Assess skin integrity ●​ Oral mucosa, lips and skin are intact, free of abrasions, ulcers, bruising rashes or reddened areas, abrasions, reddened areas, ecchymosis, rash, excoriated, laceration, ulceration, maceration, itching, petechiae. Note each area of concern separately and use metric measurements to describe. Assess skin turgor ●​ Elastic, sluggish, tenting Assess IV Site(s) ●​ IV patent or able to be flushed, non-tender with no redness or swelling, dressing is dry and intact. Pink, edema at site, reddened around site, red streaks up arm, unable to flush, dressing loose / secured, tender to palpate, tender with med admin. ●​ Note type of solution hanging and rate. Ensure this is what was ordered. Assess wounds, Note any drains, tubes coming from wound. (Penrose, Jackson Pratt-JP, Hemovac, Wound Vac) ●​ Sutures/staples/steri-strips/dressing clean dry and intact. No redness, increased temperature, or tenderness in surrounding tissues, No drainage or odour present. Edema, crusted, reddened, separated edges, not approximated, open wound, open to air ●​ Dressing: saturated, old drainage, wet to dry dressing, changed, reinforced, warm moist compress, irrigation catheters present Musculoskeletal Assess motor strength ●​ Able to make changes in position without assistance, active range of motion (ROM) to all extremities, with symmetry of strength. Absence of joint swelling or tenderness. Weak, absent, spastic, contracted, casted, traction, brace / splint in place, dressing limits movement, no movement, para or quadriplegic ●​ If needing repositioning (done every 2 hours minimally) note position moved to Assess sensation ●​ Sensation present and normal, no numbness or tingling. Numbness, tingling, pins and needles, phantom sensation, no sensation, para or quadriplegic ●​ CMS checks are done on digits / extremities that have had surgery or loss of function / sensation. CMS is done routinely every 2 hours. C=colour, M=movement, S=sensation Psychosocial ●​ Affect appropriate. When family present, interaction between family and patient is appropriate. Characteristics of appearance, behaviour, and verbalization are appropriate to developmental level. Patient and or family identify supportive networks and effective coping mechanisms. Page 3 of 4 Activities of Daily Living (ADL’s) The following should be noted throughout your charting as it becomes appropriate: Assess hygiene ●​ Bath or shower taken, sponge, bed bath, sitz bath, hair wash, done by self, assistance or total care ●​ Oral care- done by self, assistance or total care ●​ Linen change Assess diet, appetite and feeding ●​ Diet: NPO, clear fluids, full fluids, regular, sips and chips (ice), renal, cardiac, low salt, soft, minced, pureed ●​ Appetite: good ¾ to all of tray, fair ¼ to ½ of tray, poor less than ½ of tray, refused ●​ Feeding: self, set up, assist, total feed, fed via NG, NJ or PEG tube, intermittent, continuous. Note gastric residuals prior to all tube feedings (do not aspirate NJ tubes) Assess ambulatory devices ●​ Cane, walker, brace, crutches, chair, wheelchair. Note the time spent in each. Assess family contact and emotional support given ●​ Telephone call, visit – who? For how long? Family participating as possible, staying over night, no contact ●​ Support provided by nursing staff, discharge planning nurse, social worker, chaplain, other interdisciplinary staff Patient and Family Education Assess learning needs ●​ Patient and family demonstrate an interest and willingness to learn about present condition and care. Patient and family verbalize understanding of patient’s condition / care – plan of care for the day. Safety Education Document teaching regarding education given to families and patients on the following topics: ●​ Hand hygiene and infection prevention strategies used by staff, families and visitors. Document that you have described the reasons for patient isolation (if appropriate). ●​ Encourage patients to ask healthcare providers to use hand hygiene or wash hands on entrance to room. ●​ Fall prevention teaching including wearing non-slip socks or socks and shoes, as well as calling for assistance when getting out of bed, appropriate side rail use. ●​ Document Patient Transfer Level (It’s Your Move) Plan of Care / Discharge Planning Note Plan of Care for the day / shift. These goals may also be documented after the fact, at the end of the shift as accomplishments, with recommendations for the next shift to continue the plan of care. Examples of daily goals may include: ●​ Patient will tolerate using incentive spirometer device with 10 breaths at least once every hour while awake and achieve an average inspired Tidal Volume of 1500cc. ●​ Patient will tolerate being out of bed to chair for periods of one hour, three times during the day shift. ●​ Patient will tolerate without shortness of breath, walking the length of the nursing unit with 1 person assistance a minimum of three times during the day shift. ●​ Patient NPO for Diagnostic Imaging exam this afternoon. Assess outstanding teaching needs and note the status of interdisciplinary rounds, note the need for family care conference if appropriate. Note when education is provided by other disciplines. Example: Diabetic diet modification teaching reinforced with patient and spouse by Registered Dietician, educational handouts provided. Please see the RD note. START OF SHIFT ROOM SAFETY CHECKS ●​ ●​ ●​ ●​ ●​ ●​ ●​ Suction Canister present and functioning Oxygen spigot present and functioning – if patient on oxygen, ensure the correct rate. Monitor (if present) Alarms on, limits appropriate and within ordered parameters and NOT silenced. Patient is wearing their ID Armband on their body (wrist or ankle) and it is not on the bed rail or side table Side rails are appropriate up or down Call bell is within reach IV (if present) is running at ordered rate, and with correct fluid, and tubing is in date. Page 4 of 4