Head to Toe Assessment

Question 1

How do you begin the head to toe assessment?

Answer 1

vital signs (before cathy comes in!)
hand wash
provide privacy
double check that it is still a good time
ask about fluid and food if appropriate

Question 2

What would you assess during the head?

Answer 2

A and O?
PERRLA
Oral mucosa
Any troubles with swallowing such as a cough or choke?
Sensation

Question 3

What would you assess during the neck?

Answer 3

Skin tenting

Question 4

What would you assess during the arms?

Answer 4

Skin is pink warm and dry
Cap refill
Have you noticed any sores or wounds that bother you?
check for edema.

Question 5

What would you assess during the MSK of the upper body?

Answer 5

Range of motion in the neck
joint pain or tenderness in the shoulders, elbows, wrists and hands
Muscular strength of the shoulders, elbows, wrists and hands
range of motion in the shoulders, elbows, wrists, and hands

Question 6

what would you assess during the MSK of the lower body?

Answer 6

joint pain or tenderness of the hips, knees and ankles
muscle strength of the hips, knees, and ankles
range of motion of the hips, knees, and ankles

Question 7

what would you ask as you assess the MSK of the entire body?

Answer 7

How do you usually get around?
does anyone help you get around?
do you usually use assistive devices?
what do you like to do for fun?
sensation intact?

Question 8

what would you do as you assess the lower extremities?

Answer 8

pedal pulses
cap refill
check for edema
skin pink warm and dry

Question 9

what would you assess as you are doing the heart

Answer 9

listen for s1 and s2

Question 10

what would you assess as you are doing the lungs

Answer 10

listen to anterior and posterior
ask if she ever feels tired at  rest
ask if she feels tired while activity
accessory muscle use?
do you ever use oxygen?

Question 11

what would you assess as you are doing the abdomen?

Answer 11

listen over quadrants
palpate for tenderness
ask if she struggled with constipation or diarrhea
ask about fluid and food if haven’t already
nausea or vomitting
can you make it to the bathroom in time

Question 12

what would you assess as you are doing the urinary?

Answer 12

ask if she has noticed any change in color or odor
pain with urination
can you make it to the bathroom in time when you need to go
check for catheter