head to toe assessment

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why do we do an assessment?

- baseline for how the client is progressing

- 5 steps (A Delicious PIE)

1. assessment- gather data

2. diagnosis - analyze info and draw conclusions

3. planning - goals and interventions

4. implementation - carry out interventions

5. evaluation - were goals achieved.

Types of evaluatations

- initial: admission and discharge

- safety: beginning of shift

- time lapsed: beginning and end of shift

- focused: according to client status

- emergency: on everyone regardless

Gordon's functional health patterns

- nutritional/metabolic

- emlimination

-activity/exercise

-cognitive/perceptual

organize assessment

- systematic

- wear gloves if needed.

- identify the patient before touching them WASH YOUR HANDS

- assess orientation (where are they? what year is it?)

- note if they are awake and alert with eyes open

- thought processes (confused, short and long term memory)

- behavior, anxiety level and facial expressions

Vital signs

- temperature

- pulse (radial, apical will be down the road)

- respirations

- blood pressure

- pain scale (0-10)

- weight and BMI

- BMI of 25 or above is overweight, 30 or above is obese and less than 18.5 is underweight.

Head and neck

-oxygen

-assess skin condition and nares

-assess for bruises and lesions

-inspect oral mucosa tongue, teeth and gums for hydration and lesions

pupillary assessment--perrla: Pupils Equal Round Reactive to Light & Accomodation (this means that cranial nerves II and III are intact.

- note the size of each pupil (mm) normal is 3-7 mm

- compare the size

- note and compare the shapes

- move light to the side of the head with prior warning and see how fast the pupils react

- Pupils equal, Round

jugular venous distention

- 45 degree sitting patient

- caused by heart failure

- you dont want to see this, you want a normal looking neck

lymph nodes

- palpate cervical lymph nodes bilaterally

- will feel it if child or cancer patient

Anterior and posterior chest

- see practical skills lesson for different sounds in different places.

- check for cough and sputum

- listen for heart sounds (lub dub)

- apetm (all pigs eat too much) mitral is apical.

skin turgor

- dehydration status

- decreased turgor is when the skin continues to tent up after pinching it.

Wounds?

- is dressing clean, dry and intact?

apical pulse

-apex of heart

Abdomen

- look listen and feel

- inspect

- auscultate- listen

- palpate- examine by touch

- percuss- gently tap

Use good lighting

look at color, shape and symmetry

odors from skin, breath and wound

auscultation

-bell picks up low pitched sounds like heart murmurs

palpation

- back of hand to assess temp

- fingers to assess skin, turgor, texture, moisture, and tenderness

-size shape and consistency

percussion

- sound produced by striking body surface

bowel sounds

-hypoactive:listen for a full 5 minutes before determining that a bowel sound is not there. many causes

-hyperactive: ulcers, food allergies, laxative, bowel inflammation, diarhhea

- normal: 5 to 35 per minute on each quadrant

bladder

- distended is bad, when patient has to pee and can't

- watch for foley blockage

upper extremities

- IV?

- numbness and tingling

- edema

- asses range of motion

- palpate radial pulses

- assess for capillary refill

- hand grips or use two fingers

lower extremities

-pedal pulses

-capillary refill

-edema

-inspect knees, ankles and feet

-asses ROM and gait, ambulation

- assess back side and booty

Assess gait and balance

- tandem walking (heel to toe walking) adds balance requirement to gait test.

- Romberg test: ask patient to close their eyes and keep their feet together and have them balance. small swaying is okay, but if swaying exceeds a couple of inches, the test is failed.

Spine:

- kyphosis: pronounced convexity of the thoracic spine is common in older patients

- lordosis: less common, excessive concavity of lumbar spine (sway back)

- scoliosis: lateral curvature of the spine

Pedal pulses

- posterior tibial (above the ankle)

- dorsalis pedis (on top of the foot)

Interview techniques:

Observation- nonverbal communication, eye contact, body language, tone of voice, nonverbal behavior, appearence and interaction with the environment.

Open ended questions: trying to find out health goals/ cocerns in their own words.

leading question: possibly risky because it limits the information provided to what a patient thinks you want to know.

back channeling: reinforces interest in patient thru good eye contact, active listening prompts (eg. all right, go on) that indicate you are interested and want patient to extrapolate

probing: encouraging full description without controlling the direction of story (includes open ended questions)

direct close-ended questions: helps to know specific information and identify patients problems accurately.

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To test cranial nerves:

V (trigeminal) ask patient to bite down and feel for contraction of temporal muscle and masseter muscle, also light touch on forehead, cheek and chin with cotton ball

VII (facial) check for symmetrical facial features, assure eyelid on one side isn't drooping, ask patient to smile, frown, puff cheeks, raise eyebrows, etc.

cranial nerve XI ask patient to turn head with your hand on cheek for resistance.