AA NURSING
AA NURSING MED- SURGI
HEAD TO TOE ASSESSMENT Watch www.youtube.com/watch?
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Question

How can the head to toe assessment be done please.IMG_4768.jpg

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HEAD TO TOE ASSESSMENT
Watch www.youtube.com/watch?v=gG8kh8anGY HOW TO WRITE: YOU ARE TO CREATE A PICTURE
OF YOUR PATIENT General appearance: 0 Affect / behaviour / anxiety
0 Level of hygiene 0 Body position 0 Patient mobility 0 Speech pattern and articulation This is not a specific step. Evaluating the skin,
hair, and nails is an ongoing element of a fill body assessment as you work through steps 3‘9-
2. Skin, hair, and nails: 0 Inspect for lesions, bruising, and rashes. o Palpate skin for temperature, moisture, and
texture. 0 Inspect for pressure areas. 0 Inspect skin for edema. 0 Inspect scalp for lesions and hair and scalp for
presence of lice and/ or nits. 0 Inspect nails for consistency, colour, and capillary refill.

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o Palpate: 0 Four quadrants for pain and
bladder/ bowel distension (light
palpation only) 0 Check urine output for frequency, colour,
odour.
0 Determine frequency and type of bowel movements . Genitourinary: Check urine output for frequency, colour, odour. Female: vaginal discharge Male: circumcision, discharge Musculoskeletal: 0 Check if full or partial weight—bearing.
0 Determine gait/balance. 0 Determine need for and use of assistive devices. Inspect:
o Arms and legs for pain, deformity,
edema, pressure areas, bruises
0 Compare bilaterally
o Palpate: 0 Radial pulses
0 Pedal pulses: dorsalis pedis and

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'fi 0 Palpate:
0 Radial pulses
0 Pedal pulses: dorsalis pedis and posterior tibial
0 CW8 and capillary refill (hands and feet)
II Assess handgrip strength and equality. a Assess dorsiflex and plantarflex feet against resistance (note strength and equality). Back area (turn patient to side or ask to sit up or lean forward): :- Inspect back and spine. 0 Inspect coccyx/buttocks.
Tubes, drains, dressings, and IVs: 0 Inspect for drainage, position, and function. :- Assess wounds for unusual drainage.

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Sample format for documentation: General Status Vital signs Head, Ears, Eyes, Nose, Throat Neck Respiratory Cardiac Abdomen/GI GU Pulses Extremities Skin Neurological

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