2 Head to Toe Assessment Validation Sheet

Head to Toe Assessment (Adult – Bedside) Student: ________________________________________________ Faculty Evaluation *** NPSG NPSG NPSG NPSG Provide for patient privacy Wash hands per CDC guidelines Introduce yourself Identify patient correctly using two identifiers (check to armband) Verify allergy status General Survey Assess level of consciousness: Alert & Oriented x 4 (person, place, time, situation) Assess overall demeanor of patient: Mood/affect, personal hygiene Assess communication: Speech (slurred), able to articulate, hearing (Hearing aids or HOH), vision (difficulty seeing, blurred vision, double vision) Pain: Perform pain assessment (PQRST) utilizing 0-10 scale Head and Neck Inspect: Head for bumps, if needed – check hair distribution, infestations and skin integrity Inspect: Ears for drainage, placement, tenderness and any abnormalities Inspect: Face – check for symmetry – facial droop, color (pale, flushed, jaundice) Inspect: Eyes - redness, discharge – contacts, glasses, sclera, extra ocular movements, pupil size, PERRLA Inspect: Nose – overall condition, any drainage, patency (if applicable) Inspect: Mouth and gums for moisture, cracked lips, bleeding gums, tongue (swollen), can patient swallow, do they wear dentures, does the tongue move appropriately, breath odor Inspect: Neck – swollen lymph nodes – note size and location if present, JVD (at a 45 degree angle), goiter, deviated trachea Palpate: Head (sinuses) or neck (lymph nodes) if obvious abnormalities present Ask: Facial sensation, ability to smell Skin Inspect: Skin for breakdown – (ears, elbows, shoulders, hips, knees) note location and descriptors if present Inspect: Color –cyanotic, bruising, pale, jaundice Palpate: Skin for temperature – use dorsal part of hand – cool, clammy, hot, dry Palpate: Turgor (under clavicle) Braden Scale Risk: Complete assessment as indicated Upper Extremities Inspect: ROM, symmetry of extremities, able to perform ADL’s, shoulders raise and lower, joints stiff or swollen, nails pink, no clubbing noted Palpate: IV Site for tenderness and warmth if applicable Palpate: Radial, brachial, ulnar pulses bilaterally – check for deficit, +1, +2, +3, absent Palpate: Muscle strength in hands (check bilaterally) Palpate: Capillary refill in fingers - < 3 seconds or > 3 seconds Thorax, Heart and Lungs Inspect: Thorax (chest cavity), symmetry, bruising, surgery scars, inspiration and expiration, use of accessory muscles Palpate: Chest wall for tenderness if indicated Auscultate: Heart sounds Apical (PMI) – check for 1 minute Auscultate: Anterior lung fields in 6 places (including laterals) Ask: Tobacco use or other substances, respiratory conditions, cough, mucus production, use of 02 Back Inspect: Position of spine, bruising scaring, skin breakdown (includes the sacrum/coccyx) Palpate: Back for tenderness including costovertebral if indicated Auscultate: Posterior lungs fields in 8 places including bases (avoid bone) Student:________________________________________________________________ Abdomen (Gastrointestinal) (Genitourinary) Inspect: Abdomen for bulging masses, distention, bruising, tubes or drains, scars Auscultate: Bowel sounds in 4 quadrants – start in RLQ for hypo, hyper or normal Percuss: Abdominal quadrants for dull or tympanic sounds if indicated Palpate: Abdominal quadrants for masses or tenderness if indicated Ask: Presence of nausea/vomiting, difficulty eating, last BM (was it normal for patient – frequency/consistency) Inspect: Perineal area for skin breakdown, presence of foley catheter, and overall cleanliness Ask: Presence of pain with urination, blood in urine, dark colored urine, foul odor, frequency, hesitation or burning with urination Lower Extremities Inspect: Legs for symmetry, ROM, muscle strength, hips for stiffness and/or pain, skin for color, temp, bruising, and skin breakdown, hair distribution Inspect: Calves for heat, redness, swelling Inspect: Feet – overall condition, heels/ankle for skin breakdown, nails Palpate: Edema (pitting vs. non-pitting) Palpate: Dorsalis pedis, post tibial and if needed popliteal pulses bilaterally +1, +2, +3 Palpate: Capillary refill in toes – <3 seconds or > 3 seconds Ask: Ability to ambulate, use of assistive devices, and if there are any difficulties with gait (Romberg test if indicated) Safety Risks NPSG Ask: Suicidal Ideations (Do you have a plan to hurt yourself, or others) *** Morse Fall risk: Complete fall assessment as indicated Abuse Ask: History of abuse (Do you feel safe here, or at home) NPSG NPSG Ensure safe environment: bed to appropriate height, brakes locked, appropriate side rails up and call light within reach Wash Hands per CDC Guidelines Completed in 15 minutes using timer: Yes_______ No______ (***Must be completed within 15 minutes. Any items missed afterwards will not be counted***) Faculty Evaluator: Comments: Faculty Evaluation