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Notes: A Stepwise Guidebook on Filling in Head To Toe Assessment Form Online

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The Definite Guide to Head To Toe Assessment Form

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Understand How to Fill in the Head To Toe Assessment Form

this is cereth registered nurse or en.comment in this video I want to be.performing a nursing head-to-toe.assessment this video will be similar to.what you have performed in nursing.school whenever you're doing your.clinical check off now whenever you.actually start working as a nurse you'll.be able to tailor this head-to-toe.assessment to focus on the patient's.needs and you'll get a lot faster at.this so what I want to do is I want to.cover literally how to assess from the.hair on the head all the way down to the.toes so let's get started now when.you're doing your head-to-toe assessment.you follow that sequence of how you.assess each system so you start out.whenever you're looking at a system.you're going to inspect it then palpate.percuss and then auscultate except.you're gonna change it up a little bit.whenever you're going over the abdomen.you're going to inspect auscultate.percuss and then palpate and the reason.that you're going to auscultate second.instead of last is because whenever you.perform palpation percussion if you did.that before it could alter the bowel.sound.so we want to go ahead and just.auscultate get a baseline of what we can.here and then we will perk us and.palpate so first what you want to do is.you want to perform hand hygiene and.provide privacy to the patient then.introduce yourself to the patient and.explain what you're going to be doing so.hello my name is Sarah and I'm going to.be your nurse today.and I need to perform a head-to-toe.assessment is that okay with you okay.then proceed and look at their arm bands.so what while you're doing this this is.gonna help you make sure you have the.right patient and you're gonna be.testing them to see if they know who.they are their date of birth and ask.them some other questions to assess that.neuro status so say your first and last.name for me first name is being last.name is Dover okay and your date of.birth.a 2882 okay and do you want me to call.you Ben or mr. diver why do you have.everything okay so then can you tell me.where you're at I'm at the hospital okay.and can you tell me what we're doing.here today.okay and who's the President of the.United States Donald Trump okay.so he answered all those correctly and.he's alert and he's oriented times four.he knew who he was he's able to tell me.his name his date of birth where he was.what we're doing and current events so.we can chart alert Maureen at times for.then you want to collect vital signs.such as the patient's heart rate blood.pressure temperature oxygen saturation.respiratory rate and the patient's pain.rating so Ben are you having any pain on.a scale zero just hand with zero being.no pain at all intending the worst pain.you've ever had okay and I have a video.on how to assess those vital signs in.depth if you want to watch that video.and a card should be popping up so you.can access that video then after that.what you want to do you can collect.their height and their weight and look.at the BMI their body mass index.remember if it's 18 point 5 or less.that's underweight or if it's greater.than 30 that is obese now why you been.doing all that asking me these questions.doing their vital signs you're also.before you've even really assessed the.system you are already collecting.information for instance how is that.patient responding to you what's their.emotional status are they calm are they.I just hated are they drowsy what's.going on with him do they look their.stated age does his skin color match his.ethnicity is he does he understand my.questions or does he seem like he can't.hear them very well.or is there a delay whenever he responds.to me or does he respond appropriately.and at an appropriate time also do you.notice any just outward I'm more.maladies like an amputation any masses.lesions it's his skin sweaty cold and.clammy do you notice any sign oh so it's.right off the bat also do is his hygiene.good and it says posture good and you.notice any.normal smells but during all that you're.really collecting all that information.now what we're going to do is we're.going to start with the head and move.our way down to the toes so we are first.going to inspect the head and we are.looking at the skin color he it's nice.and pink we're also going to make sure.that the head is the same size as how it.should be for the body and it is and.we're looking for any abnormal movements.or twitching of the face that he can't.control that are involuntary we don't.see anything and we're making sure that.the face is symmetrical there's no.drooping on one side like in this.picture there's drooping on one side of.the face and this can be seen in Bell's.palsy or in stroke and we're also just.looking at the eyes and the ears or they.have the same level and while we're here.we're gonna go ahead and look at the.facial expressions and test cranial.nerve seven which is the facial nerve.so can you close your eyes tightly for.me and open them up okay now smile for.me frown and pop out your cheeks okay.and he did that with E so that cranial.nerve is intact next what we're gonna do.is we're gonna palpate the head the.cranium we're gonna check for any masses.indentations look for skin breakdown any.infestations and for this part I like to.wear gloves so let's look at the hair so.what we're doing is we're filling for.any masses indentations and also with.this we're looking for any skin and.breakdown and if your patients in mobile.you really want to check the back of the.head back here because they're laying on.it a law and there can be breakdown back.there.also while you're doing that look inside.the hair make sure there is no.infestations like lice and there's no.abrupt like rounding areas of baldness.which could represent alopecia then.after that since this patient has a.beard you want to check the beard as.well any lesions any infestations or.anything like that and just look around.and then once you're done with that what.you want to do is you'll doff your.gloves and perform.and hygiene next what we're going to do.is we're going to find the temporal.artery and we're going to palpate them.bilaterally and they are both found.right here and that his are about a two.plus and then while we're right there.we're gonna go ahead and test cranial.nerve 5 which is the trigeminal nerve.and this nerve is responsible for many.things like massification so what I'm.gonna have you do bian is I'm gonna have.you clench your teeth like bite down for.me and I'm going to feel the masseter.muscle which is right there there should.be a nice firm ball and then feel the.temporal muscle now what I'm going to do.to also test that nervous have him try.to open his mouth against resistance so.try to do that for me okay and he can do.that now while we're here we're going to.go ahead and feel the temporal.mandibular joint and we're gonna feel.right here and I'm gonna have you open.and close your mouth and I'm feeling for.any grading or clicking sensations and I.feel none then we're gonna palpate the.sinuses and I'm going to put pressure on.these two sinuses right here and you.tell me if you feel any pain okay so the.max max lip maxillary yeah in the.frontal no next we're moving down to the.eyes and we're going to inspect the eyes.first and we're looking at several.things we're looking at the eyelid we're.looking at the sclera which is the white.of the eyes we're looking at the iris.we're looking at the pupil and we're.looking at the conjunctiva so you.shouldn't see any swelling of the.eyelids you should see that the sclera.is why and shiny it shouldn't be yellow.like in jaundice and the conjunctiva.when you pull down the lower lid have.the patient look up it should be nice.and pink it shouldn't be red you.shouldn't see any drainage or anything.like that and look at the eyes how do.they set in the eye socket is are they.equal four instances is there any.strabismus is there a cross eye where.one eye turns in more turns out or up or.down and these eyes are normal there's.no strabismus next you want to look at.Ana.Coria where you have where one pupil.would be smaller than the other people.are they equal in size normal pupils.should be three to five millimeters in.their measurement and here his are about.a three and they are equal next what.we're gonna do is we're going to assess.some cranial nerves we're gonna be.looking at cranial nerve three which is.ocular motor for troch Euler and then.six which is abducens and we're gonna do.several tests to check their function.the first one what we're gonna do is.we're going to be looking for any.involuntary shaking of the eye called.nystagmus and how we're gonna do that.was we're gonna take our pin line we're.gonna hold it about twelve to fourteen.inches away from the patient's nose and.then what I want you to do is keep your.head still don't move your head and just.use your eyes to watch where I move the.pin line and as you're doing this you're.going to do you're going to perform it.in the six cardinal fields of gaze and.you're just going to move it you're.looking for any involuntary shaking of.the eyes so here we go.next we're going to see how reactive the.pupils are to lie and to do that we're.going to dim the lights a little bit and.we're gonna have the patients stare off.at a distant object that helps dilate.those pupils and then we're going to.shine using our pin line in at the side.and we're gonna see how that pupil.response is she constrict and then on.the other side it should constrict as.well so say their baseline pupil size.was like three millimeters it should go.down to one milliliter and it should.happen on both sides okay so being stare.off at that object rod on the wall over.there for me okay.and that dilates the people's and we're.just going to shine light in at this.side okay constrict constrict okay I'm.dilate again then go over to the other.side do the same again.and they both constricted and equal size.next what we're gonna do is we're gonna.check for accomodation and how we do.that is we turn the lights back on we.just previously had them dimmed but we.now make it light again we're gonna have.him stare off at a distant object that.helps dilate the pupils and we're going.to take a pin light you can use a pin.light finger and you're just going to.slowly move it inward to the nose and.what you're looking for is that those.pupils constrict they accommodate and.the eyes cross while looking at the pin.line so here we go stare off in the.distance please and I don't want you to.move your head or anything just keep it.real still and just follow this pin.light okay ready.okay so now we can document because we.just checked all of the things with the.eyes we can document that the pupils are.equal round reactive to lie in the.accommodate so that's where that acronym.perrla comes into play next we're going.to move on to the ears so first what we.do is we inspect the ears we look on the.outside of the ear is there any.abnormalities any redness any drainage.anything like that and then are you.having any pain in your ear okay and.sometimes if you have patients who've.had long-term gout on the helix of the.ear they may have what's called a Toph I.which is an accumulation of like a.whitish yellowish uric acid crystals on.the skin so if you ever see that that is.what that looks like next we're going to.palpate on the ear we're just gonna move.it around and being tell me if you have.any tenderness whenever I do that and.any feel any abnormal masses or lesions.and then move the targets a little bit.does that hurt or anything like that.okay so no pain or tenderness then we're.going to palpate the mastoid process.which is the big behind the ear.and we're looking at it is it swollen is.there any redness and whenever I touch.on again does it hurt okay and just see.if the patient reports any tenderness.with that then while you're there you.can use the otoscope to inspect the.tympanic membrane and remember the.tympanic membrane should be a pearly.gray translucent color and should be.shiny so for an adult you're going to.pull the pin of the ear up and back and.we're just going to inspect it and also.while we're looking at that we are.looking at the cone of light and.remember the cone of the lie in the.right ear should be at five o'clock and.in the left ear should be at seven.o'clock next we're going to do one more.thing with the ear we're gonna test.cranial nerve eight which is the best.tibula cochlear nerve and what I'm going.to do is I'm going to include one of his.ears and then whisper two words on the.other side he needs to tell me what I.so you ready okay I'm gonna clued this.one okay very good okay and that nerve.is intact next we're gonna move on to.the nose and we're going to inspect the.nose we're gonna make sure it's midline.on the face which it is we're gonna look.at the septum is it deviated anything.like that and ask the patient or you.have any trouble with your nose are you.having any drainage or anything like.that.no and you want them to make you want to.check the patency of the nose I mean I'm.gonna have you a clued one side of the.nostril breathe out the other and vice.versa okay heard airflow airflow nice.and Paton cuz sometimes people can have.polyps that can block it or the deviated.septum then you want to take your pin.light and you just want to look inside.the nose look for any drainage redness.or any like polyps or anything like that.and everything looks clear don't see.anything and then we're going to test.the olfactory cranial nerve one the.sense of smell so Ben what I'm gonna.have you do is I'm gonna have you close.your eyes and I'm gonna put something in.front of your nose and have you breathe.in and smell and you tell me what you.smell and whenever you do this use.something that's pleasant smelling not.something that's really stinky cuz it.could elicit like a gag reflex or.something like that if the person has a.sensitive nose okay okay and this was.vanilla extract and that's correct.so that cranial nerve is intact next.we're gonna move on to the mouth and for.this part like to wear gloves and if.your patient is coughing and hacking you.might want to wear a mask with a shield.so you don't get any mucus on your face.or in your mucous membranes so first.what we're gonna do we're just.inspecting the lips make sure they're a.nice pink color they're not chapped.there's no sores on them and one thing.with a lot of patients whenever their.oxygen saturations are load their lips.may turn dusky or a blue color so you.wanna make sure they're nice and pink.because that can represent our oxygen.level now let's inspect the inside of.the mouth but first let's test cranial.nerve 12 which is the hypoglossal nerve.and what I'm gonna have you do man is.I'm gonna have you stick out your tongue.and maybe bit side to side okay and he.does that with ease now what we're gonna.do is we're going to inspect the inside.of the mouth you'll need a tongue blade.for that and just open up your mouth for.me and I'm gonna look on the inside of.the cheeks nice and pink don't see any.sores you're looking to see if they're.nice and pink and there's no lesions or.anything like that and stick out your.tongue for me the tongue should be moist.like this and pink you don't want to be.beefy red which is like an pernicious.anemia you don't want to be dry or.cracked that could be dehydration okay.you can put the tongue in then I want.you to lift up your tongue for me and.look for any lesions underneath the time.that's where mouth cancer can hang out.and I don't see any okay you can close.then you'll why you're also looking at.the gums open up a little bit.you're gonna look around for cavities.any loose or broken teeth no dental.caries in there then okay sort of open.up your mouth a little bit more put your.tongue down and you're gonna look at the.soft and hard palate now while you're in.there you want to look at the uvula.make sure it is nice in midline and his.is nice and midline and we're going to.test cranial nerve nine the glaucio.pharyngeal and so what I'm gonna do is.I'm gonna have you say ah and what you.want is that you've loved to move up.okay and then we're just gonna test the.gag reflex I'm sort of just gonna poke a.little bit back there and elicit a gag.reply okay there you go CAC is really.good and cranial nerve 10 the vagus is.intact because he's able to talk wasn't.talked to me without hoarseness and he's.able to swallow then when you're done.inspecting the mouth be sure you take.off your gloves and perform hand hygiene.now moving on to the neck so what we're.going to do is we're going to.the neck first so you're gonna have the.patient extend the neck up a little bit.and you're looking at that trachea is it.midline look for any lesions and look.for any lumps like what you might see.and thyroid problems like a Gorder and.we don't see any of that then what we're.gonna do is we're gonna test cranial.nerve 11 which is the accessory nerve so.being what I'm gonna have you do is move.your head side to side up and down okay.and then shrug try to shrug against my.resistance and he does that with ease so.that nerve is intact.then we're gonna place him at a 45.degree angle and we're gonna have him.turn his head to the side and what we're.looking at is the jugular vein we're.looking for any jugular vein distension.jvd so Ben I'm gonna just turn your head.to the side like that and we're looking.for any distinction of the vein and we.do not see any next what we're gonna do.is we're going to palpate so we're gonna.palpate that trachea just to confirm it.is midline and Ben do you feel any.tenderness or anything like that ask him.if he feels any tenderness and I don't.feel any lumps then next what we're.going to do is we're going to palpate.the lymph nodes all sites of those and.being as I do this tell me if you feel.any tenderness and what I'm feeling for.is any hard lumps or anything that may.be inflamed so what we're gonna do turn.a little bit this way and there we go.we're gonna start at the pre auricular.which is right in front of the ears then.we're going to go to the back of the.ears the posts are regular then we're.going to go to the opposite battle the.parotid jugular digastric then we're.going to go to the submandibular and.then the submental then we're gonna go.to the superficial cervical and then.we're going to make our way down to the.deep cervical chain you need tenderness.so far then we're going to go to the.posterior cervical and then right above.the clavicle we're going to go to the.Supra.clavicular and did not feel anything and.no tenderness next we're gonna palpate.the carotid artery and this is one.artery that you do not palpate.bilaterally you do one individually so.we're gonna fill on this side and you're.gonna find it next to where the groove.of the neck and next to the trachea and.his is nice and bounding it's two-plus.then we're just going to fill on the.other side and same strength too plus.then lastly what we want to do is we're.going to auscultate the carotid artery.and you're gonna do one side at a time.and you're going to compare sides and.you're gonna listen with the Bell of.your stethoscope and we're listening for.a bruit.which is a swishing sound so being what.I want to do is I'm gonna have you.breathe in breathe out and hold it for.me okay go breathe in breathe out okay.breathe normally now did not hear it on.that side okay breathe in breathe out.for me and hold it okay and I did not.hear a bruit on that side as well now.let's move to the upper extremity so.what we're gonna do is we're gonna.inspect the extremities and we're.looking for any lesions any redness.swelling and this is a good time if they.have a central line an IV that you look.at that make sure it's not red does the.IV need to be changed that's that PICC.line or central line need a dressing.change assess that then you can palpate.and what we're gonna do is we're going.to palpate our pulse or radial artery so.fill those bilaterally and they are two.plus and they're equal then we're gonna.check capillary refill and to do that.we're just gonna press down on that nail.bed and see how fast it comes back in.it's less than two seconds then we're.gonna check skin turgor Bobbitt just.pinch in the skin and see how fast it.goes back and that was good then we're.just gonna look at the range of the.motion of the.angers and the hands look at these.joints in the hands you see anything I'm.normal like for instance like her.bidding or both shards nodes which are.found in osteoarthritis and ask the.patient are you having any pain in your.hands or anything like that no then you.can palpate the brachial artery which is.found in the bends of the arm and just.fill those because that's another pull.site and those are two plus and just as.a side note if this was a patient that.was getting dialysis and they had an AV.fistula you would want to palpate that.and feel for the thrill make sure that.that is present up in that arm wherever.their fistula is at then you want to.test the muscle strength so what we're.gonna do is I'm gonna have you squeeze.my fingers as hard as you can okay okay.that's really good.then I'm gonna have you push up against.my hands and I'm gonna push up against.your arms okay push okay very good okay.and five-plus normal strength then we're.just going to test his put your hand.underneath the elbow and just feel as.you move the arm do you feel any grading.crepitus of those joints one times an.arthritis you can fill that and move.that bilaterally another thing you want.to do with the upper extremities is to.check for a drift and what you will do.is you'll have the patient hold out.their arms and close their eyes hold it.up for about ten seconds and you're.looking for a drift like this so go.ahead do that and close your eyes okay.and we're assessing to see if this hand.will drift upward and a lot of times if.a patient has had a stroke okay you can.put them in has had a stroke or.something like that you will see a drift.next we're moving on to the chest and.we're going to inspect the chest we're.looking for any abnormalities like.lesions or any wounds anything like that.we're also inspecting the patient's.effort of breathing is it really labored.are they using those accessory muscles.to breathe also we're looking at that.anterior posterior diameter.turn to the side like that and you're.looking for that barrel chest and will.be increased in patients with like COPD.they will have what's called the barrel.chest and now what we're going to do is.we're going to listen to heart sounds.and then we're going to listen to lung.sounds so first let's auscultate heart.sounds and we're going to do this in.five locations and they're based on.where the valves are located and I like.to remember the pneumonic all patients.effectively take medicine and the first.letter of each word represents the valve.except for effectively so a would be.aortic P and patients would be pulmonic.effectively would be herbs point and.this is just the halfway point between.the base of the heart and the apex of.the heart and there's no valve location.there and then t is for tricuspid and.then n is for medicine so again using.the diaphragm we're gonna listen at the.right of the sternal border at the.second intercostal space and that's.going to be the aortic valve so to find.that second intercostal space find the.sternal notch go down to the angle of.Luis and then just go a little bit to.the right and you're in the second.intercostal space and this will be the.aortic and we're just listening lub-dub.lub-dub s1 s2 and s2 the dub is going to.be louder in this location then we're.going to go a little bit over to where.the pulmonic valve is found that's on.the left of the sternal border at the.second intercostal space over just right.across again just listening to love dub.lub dub and s2 dub is going to be louder.in this location then we're going to go.a little bit down to the third.intercostal space and this is herb's.point and again and here lub dub but.there's no specific valve here then.we're going to go down to the fourth.intercostal space and this is where the.tricuspid valve is and love s1 is going.to be the loudest at this location then.we're going to go to the fifth.intercostal space midclavicular line and.we're going to listen to the mitral.valve and.in s1 is going to be loud us hear dub.and there's something special about this.site this is the point of maximal.impulse this is where you're going to.listen for the apical pulse so we're.gonna sat here and we're gonna counter.it for one full minute and a normal.apical pulse an adult should be 60 to.100 beats per minute and his apical.pulse was 63 then we're going to switch.over with the Bell of our stethoscope.and we're just going to repeat in those.locations and we're specifically.listening for heart murmurs so that's.swishing blowing sounds so that's what.we're going to listen to with that.and I did not hear any now let's listen.to lung sounds now when you're listening.to lung sounds you're listening for.abnormal sounds and here are some.samples of some abnormal sounds that you.may hear crackles wheezes a friction rub.or Strider first we're going to listen.antara ly and what we're gonna do is.we're gonna listen with the diaphragm.over stethoscope and we're gonna start.at the apex of the lungs and we're gonna.always compare sides and just enter way.downward and assess all the lobes of.that right and left lung so first let's.start up here okay and once you take.good deep breath in and out so here we.go apex okay we're gonna compare sides.then we're gonna move down to the second.intercostal space and this is going to.help us assess the right upper lobe and.the left upper lobe so another deep.breath in and out then we're going to go.down to the fourth intercostal space and.we're going to assess where our right.middle lobe is and our left upper lobe.because remember the right lung has.three lobes and the left lung has two.lobes so let's listen to our left upper.lobe.we're just gonna go down a little bit.more then we're gonna go mid-axillary at.the Sikh six intercostal space and we're.gonna listen to the right and left lower.lobe so you just want to turn to the.side right there till you get the.present okay other side.okay now let's listen post eerily again.using the diaphragm with the stethoscope.you're gonna start listening at the apex.and work your way Dale and and one thing.to keep in mind when you're listening.back here you have the scapula and you.don't want to listen over those because.you won't be able to hear the sound so.you're gonna listen in between where the.scapula and the spine are so down in.these regions right here and again we're.just going to compare sides and you can.do this part at the end if you wanted to.whenever you turn your patient over to.look at their backside but we're just.gonna go ahead and do it now so we're.gonna start parent your pecs compare.sides then we're going to find c7 which.is that vertebral prominence it's the.big ball right there you can't miss it.and go down to about t3 and you'll be in.between the shoulder blades and go a.little bit in between the shoulder.blades and the spine right in there and.you're gonna assess the right and left.upper lobes.then from t3 to t10 we're just going to.inch around and we're going to listen to.the right and left lower lobes.okay now we're going to assess the.abdomen and remember we're switching our.sequence and how we assess we're going.to do inspection auscultation and then.percussion or palpation so we're going.to do auscultation ii so whenever you're.looking and assessing the abdomen have.the patient lay on their back and what.we're gonna do is we're going to inspect.the abdomen and first we want to ask Ben.are you having any stomach issues at all.no okay and when was your last bowel.movement yesterday morning and how are.you urinating do you have any pain while.you're peeing do have problems starting.a stream any discharge anything like.that okay and with your male patients.you want to ask about that due to.prostate enlargement was starting a.stream and if he was female I would ask.him when his last menstrual period was.and also again ice to be more patient.about urinating and things like that now.if the patient had a Foley this is the.time when you would want to look at the.urine inspect the Foley and look at that.just conglomerate your urinary system in.your GI system together.okay so we're inspecting the abdomen.we're looking at the abdominal contour.and this patients is scaphoid it goes in.a little bit you can also have flat.around it or protuberant and also we're.going to know if there's any pulsations.a lot of times in this area right here.on thin patients like with being I can.see the aortic pulsation in this.patients rod above the umbilicus and.looking at the belly button and checking.for any masses do we see any hernias or.anything like that also if your patient.had any wounds you wouldn't want to look.at that and if they had a PEG tube you.wouldn't want to assess the site make.sure it's not red and ask them how it.feels and with your ostomies with your.ostomies you would want to look at the.stoma and make sure it is like a rosy.pink color it's not a dusky cyanotic.color and it's not prolapsed and look.and see what type of stool it's putting.and note that note the smell note when.if the bag needs to be changed anything.like that so now we're ready to listen.to the bowel sounds and what we're going.to do is we're going to listen with the.diaphragm of our set the scope and we.are going to start in the right lower.quadrant and work our way clockwise and.we're gonna listen all four quadrants.and you should hear five to thirty.sounds per minute and if you don't hear.any bowel sounds you need to listen for.five full minutes and you need to note.are these normal are they hyperactive or.hypo active so let's listen this is our.right lower quadrant we're gonna move.out to the right upper quadrant move.over to the left upper quadrant and then.down to the left lower quadrant ambassy.ons are normal now we're gonna listen.for vascular sounds and you're gonna do.this with the bell of your stethoscope.and we're gonna listen at the award ik.we're gonna listen at the renal arteries.iliac arteries and you could listen at.the femoral already arteries if you need.it to so you're gonna listen at the.aorta artery and it's a little bit below.the xiphoid process a little bit above.the umbilicus so about right here and.we're listening for like a blowing.swishing sound that which would.represent a bruit okay and none is noted.then we're gonna listen at the right and.left renal arteries which is a little.bit down from the aorta location so.here's the right okay none note it and.then over the left.then we're gonna listen at the iliac and.it's a little bit below the belly button.right here and this is Illya Carter II.and then listen on the other side and.again like I pointed out you could.listen at the femoral artery in the.groin if you needed to now we're going.to do palpation first we're gonna do.light palpation then deep and being as I.do this please tell me if you feel any.pain or tenderness so first we're gonna.do by palpation we'll just start in the.right lower quadrant work her way around.and you're gonna go about two.centimeters and you're just feeling for.any rigidity any lumps masses anything.like that how's that feel okay okay now.we're gonna do deep palpation and we're.gonna go about four to five centimeters.so a lot more deep then again you're.just feeling for any masses lumps and.then tell me if you have any tenderness.and sometimes you can do this with two.hands if need be if you're not strong.enough me telling anything feels.nice and soft hurts some belly sounds.that's why you do this after you listen.cuz you stimulate it good now we're.going to assess the lower extremity so.first of all we're gonna do is we're.going to inspect we're gonna look at the.color from the legs to the toes making.sure it's nice and pink and here we see.that being has a little bit of a tan.line here and we're looking at the hair.growth as well you want to make sure.there's normal hair growth because of.PVD you will see hairless shiny thin.legs and here we have excellent hair.growth and also do you see any abnormal.swelling just right off the bat before.you've even touched the patient and look.at the legs and the feet for any.swelling redness swelling do you have.any pain or.in your legs anything like that and.looking at the joints make sure there's.no redness on the joints because a lot.of times with gout it likes to start out.in the big toe so make sure that.everything looks good and then on your.diabetic patients make sure you look at.the bottoms of their feet because these.patients don't have the best feeling in.their feet so their shoes could be.wearing on them or they kind of stepped.on something and not even know it so.inspect those feet make sure there's no.ulcers or anything that like that that.needs to be addressed also look at the.toenails so the toenails look healthy or.is there fungus are they missing.toenails they have a really bad ingrown.toenail so assess for that next you want.to palpate your pulses will palpate the.popliteal pulses which are behind the.knee and those are about two plus.they're equal bilaterally I'm just.filling his legs they're nice and warm.and I'm going to push over his tibia.firmly and I'm seeing if there's any.edema so push there and if there is a.d-mail a lot of times when you push down.it's like this hard like type gel.they'll just separate and your finger.will leave this indention in here we.don't have any now we're going to.palpate on the feet and we're gonna feel.on the pulses and I'm gonna Don gloves.perform hand hygiene and Don gloves and.we're gonna feel on the pulses and this.feet we're gonna feel on the posterior.tibial.2plus really good and then we're gonna.fill the dorsalis pedis which is on top.of the foot to plus with that and if you.can't ever find these because sometimes.these are hard to find in patients you.can get a Doppler if you have one on.your floor next we want to check the.capillary refill on his toes just like.how we did with the fingers by pushing.down in less than two seconds check the.other one.okay now I'm going to have him push.against my hands push against my hands.in okay good job now I'm gonna have you.raise your legs against resistance good.job now we're gonna check the Babinski.reflex and you can use your reflex.hammer for this and use the end of it or.you can use your finger if you don't.have that and what we're gonna do is.we're going to take this up through the.ball of the foot and curve it and we're.looking for the toes to curl in which.would be a negative normal response so.let's check that okay okay and that was.normal then we're gonna Dolf our gloves.and perform hand hygiene and next we're.going to assess the back so whenever.you're looking at the back side you're.gonna look from the head all the way.down at the back and you really want to.pay attention to any abnormal moles.lesions wounds anything like that and.assessing for skin breakdown especially.on your patients who are mobile so that.would really be concentrating on in the.backside area on the coccyx because.that's where a lot of breakdown happens.and on the back of those heels if you.couldn't see it whenever you were.assessing the feet and also you could if.you hadn't already you could listen to.the lung sounds as you have the patient.over on the back okay so that wraps up.the nursing head-to-toe assessment now.please be sure to check out my other.videos because I have a lot of in clicks.review videos to help you study for.NCLEX along with other nursing skill.videos career tips and everything you.need to succeed in nursing school all.the way to becoming a nurse in your.profession so thank you so much for.watching and please consider subscribing.to this YouTube channel.

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Head To Toe Assessment Form FAQs

Follow the below common doubts about Head To Toe Assessment Form . Reach out to directly if you still have other queries.

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Do military members have to pay any fee for leave or fiancee forms?

First off there are no fees for leaves or requests for leave in any branch of the United States military. Second there is no such thing as a fiancée form in the U.S. military. There is however a form for applying for a fiancée visa (K-1 Visa)that is available from the Immigration and Customs Service (Fiancé(e) Visas ) which would be processed by the U.S. State Department at a U.S. Consulate or Embassy overseas. However these fiancée visas are for foreigners wishing to enter the United States for the purpose of marriage and are valid for 90 days. They have nothing to do with the military and are Continue Reading

How can I fill out Google's intern host matching form to optimize my chances of receiving a match?

I was selected for a summer internship 2016. I tried to be very open while filling the preference form: I choose many products as my favorite products and I said I'm open about the team I want to join. I even was very open in the location and start date to get host matching interviews (I negotiated the start date in the interview until both me and my host were happy.) You could ask your recruiter to review your form (there are very cool and could help you a lot since they have a bigger experience). Do a search on the potential team. Before the interviews, try to find smart question that you are Continue Reading

How do Koreans take such good care of their skin?

As much as we wanted to follow the famous 10-step skin care of Koreans. For a real talk, some of us really can’t follow it. It may be due to time, some of us are tired of work and just go to sleep directly. Others have time but not the ingredients or products that they use. I have a friend who visited Korea for a vacation. By the time she got home, her skin slightly improved. But when the following weeks came, her skin totally changed for the better. It is now whiter and smoother than before and it feels like it is rejuvenated. I asked her, on what did she did to her skin. And she answered that Continue Reading

How do you know if you need to fill out a 1099 form?

It can also be that he used the wrong form and will still be deducting taxes as he should be. Using the wrong form and doing the right thing isnt exactly a federal offense

How do I fill out the form of DU CIC? I couldn't find the link to fill out the form.

Just register on the admission portal and during registration you will get an option for the entrance based course. Just register there. There is no separate form for DU CIC.

Why do you do a head to toe assessment?

To establish a baseline condition for your patients, gather assessment data to help determine health status and/or to determine if there are any changes from the hand-off report.

What is your primary goal of performing a comprehensive physical exam?

The answer to this question is best answered with a question: What role would you like your website to play? For example, a blogger who shares experiences and how she feels about them may just want a place to more or less keep a journal of her journey through life. Another blogger may be a freelancer who created a website to show off his portfolio. Other websites sell products and services, while still others publish the latest news. I could go on, but you get the idea. In the end, the role your website plays is really up to you and what you hope to accomplish with it.

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