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How to Perform a Head to Toe assessment

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Posted 9 months ago

 

Hello successfully made it through Fundamentals of Nursing and Drug Admin and Calculations with B's wanted A's but hey I passed that is all that matters. I am in Med-Surg 1 now and unlike our previous clinicals we are actually at the hospital now instead of the nursing home. It is definitely a much faster pace and at times I feel lost because the basics of what we were supposed to do last quarter to fully prepare us for our 1st day at clinicals this quarter really didn't happen. We were supposed to learn how to do a head to toe assessment and charting but we never got around to these things for various reasons.



I really want to know how to complete an assessment properly so if anyone has any tips on how this should be done it would be greatly appreciated. We got a very quick demo on one of the practice mannequins but haven't done it ourselves on the mannequin or a real patient. I dont want to return to clinicals Monday and not know what I am doing. So any tip would be nice.



Thanks in Advance



Crystal

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Rate This | Posted 9 months ago

 

Hey Crystal!


Congrats on passing forst semester!  Are they looking for you to do the long version or the short version of the head to toe?  There's a BIG difference.  LOL   Once I know that maybe I can help a bit.



~ Melissa

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Rate This | Posted 9 months ago

 

Not quite sure which one. I'm assuming a short one for now because our instructor did it on the mannequin in like 5 minutes.

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Rated: +1 | Posted 9 months ago

 

ok....welll that's good for you then.  Here's what we were taught.....


1  Introduce yourself


2  stand at foot of bed while talking to pt --- and asking questions from step 3 and 4--- lift up covers to reveal their feet and calves (check for skin temp, edema, dorsalis pedis pulse, muscle strength, and check for babinski with your finger to the bottom of their foot)


3  ask how pt is feeling, how they slept last night etc.  (checking for LOC)


4  ask pt where they are (checking for LOC)


5  ask pt what their name is and check against wrist band (checking for LOC)


6 check for PERRLA


7 check pulses (radial, brachial)


8  brief visual inspection of head, neck, chest, abdomen 


Put your stethescope on and begin auscultation (don't take it off until you've done lungs, heart, and bowel sounds)


8 perform cardiac assessment  (APETM)


9 perform lung assessment (front and lateral)


10 perform abdominal assessment (1 site in each of the 4 quadrants)


11  check for femoral and popliteal pulses


12  turn pt on side and auscultate lungs


 


Depending on the particular patient you would also check pertinent things that apply (IV site, wounds, dressings, etc etc) 


 


I hope this helps!!!!!!!!!!


~ Melissa

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Rate This | Posted 9 months ago

 

Thanks Melissa