Head To Toe Essay

Submitted By jennifermarie12
Words: 895
Pages: 4
Open Document
1) Swipe
“Hello my name is Jennifer, I’m going to be your nurse today. How are you doing?”
Wash hands.
“Can you tell me your name and date of birth” Look at wristband.
Close curtain. Wipe down bedrails and table.
“I know this sounds silly but do you know where you are today? And what brought you in today?”
“Patient is alert and oriented”
“Today I am going to do a head-to-toe assessment if that’s okay with you. It’s just a test of your different body systems to get some important data.”
2) Neuro
“I’m going to start by assessing your cranial nerves to make sure they’re all functioning properly, first will be cranial nerve 1, which is scent”
Use alcohol swab for each nostril, ask if smell is equal on both sides.
“Now I’m going to check your eyes”
Use Snellen chart. Tell patient to focus on something in the distance and then follow penlight toward the nose. Check pupil accommodation to light. 6 cardinal fields. Peripheral vision by wiggling fingers from behind patient toward face. Then cover one eye and do again, then other eye.
“Now I’m going to check your hearing”
Use whisper test
“Now I’m going to check your facial nerves”
Palpate jaw bone while patient open and closes mouth. Have them close eyes and touch face with cotton.
“Now I just want to check for facial symmetry, can you smile for me? Now raise your eyebrows. Now puff out your cheeks and I’m going to press them”
“Can you shrug your shoulders for me? Now can you turn your head against my hand?
“Now I just need you to swallow, great now can you stick out your tongue and say ah? Perfect, your uvula raises and stays midline and your tongue stays midline. Now just repeat after me, light, tight, dynamite.”
3) Head
“Now we’re on to the head part of the assessment. I am just inspecting your head for symmetry, general size, and shape. Head is normocephalic!”
“Your facial expression is appropriate, there is no abnormal swelling.”
Palpate skull for symmetry and smoothness, lesions, lumps, bruising.
4) Ears
“It looks like your ears have bilateral symmetry, they aren’t swollen or thickening, the color is normal and the skin is intact”
Ask if patient feels any tenderness while moving cartilage and pushing tragus.
5) Eyes
Inspect eyes for bilateral symmetry. Check for smooth eyebrows and thick eyelashes. Pull top and bottom eyelids to check for crusting and discharge.
6) Nose
“Your nose is symmetric and midline. Your septum is proportionate. Palpate, ask for pain. Frontal (right above eyebrows) Maxillary (next to nose) Make sure orbital bone is intact.
7) Mouth and Throat
Have patient open mouth. Inspect mucous membranes for color, lesions, plaques, moisture. Check teeth and gums for dental carries. No cracking of lips.
8) Neck
Check that trachea is midline

Palpate all lymph nodes, Small circular motions. “If enlarged more than 1cm, it would indicate localized infection or allergy and follows the direction of lymphatic drainage.
Preauricular-in front of ears
Postauricular-behind ears
Occipital-base of skull
Submental-under chin
Submandibular-middle of jaw
Jugulodigastric-beginning of jaw
Cervical chain
Supraclavicular-ask patient to shrug shoulders
Thyroid-apply pressure to one side and palpate other side. Ask patient to swallow.
Assess extension, flexion, right and left lateral bending and right and left rotation of head.
9) Neck
Palpate carotid artery ONE SIDE AT A TIME.
Auscultate carotid artery using BELL.
“I don’t hear any bruits. That’s what I like to see.”
10) Skin, hair, nails
Assess skin for dryness,
Show More

Related Documents: Head To Toe Essay

Head-To-Toe Assessment

is to take care of the patient and make sure their needs are met. I needed to ask the visitors to step out of the room, so I could give my patient the proper care she deserved. Being more confident is one thing I would do differently. 2.B. Head-to-toe assessments are great when gathering information with a patient that is talkative. Luckily, my patient was very talkative and gave me a lot of information about her background, family, and medical history. I looked over her charts on the hospital…

Words 416 - Pages 2

Nursing Head To Toe Assessment

to nurse’s questions upon her arrival. Student 2- You are the registered nurse. You come into the patient’s room and find the patient on the floor, soiled. You press the call light for the CNA to come and assist you, followed by conducting a head to toe assessment. You ask the patient how he ended up in the floor and if he is having any pain. You get the patient in the bed, change his soiled clothing/linen, and gesture for the aid to meet you in the hall. In the hall you ask the CNA if she was…

Words 414 - Pages 2

Comprehensive-Head To Toe Assessment

information that I am learning is completely new to me, as the newborns body greatly differs from that of an adult, I plan to put forth a great deal of effort in becoming competent in this particular field of practice. I plan to perform comprehensive head to toe assessments and with the results, accurately interpret the findings. Furthermore, my goal is to research and understand the pathophysiology to the best of my ability and use this information to provide the best and most effective care to my patients…

Words 300 - Pages 2

Head To Toe Case Study

skill that must be also mastered. First you would identify yourself, where you calling from, and about which client, then the use of SBAR is recommended, the situation that the patient is presenting, the assessment you did of that situation (VS, head to toe, or focused assessment of any system), the background of that patient (current and past medical history), and any recommendations that you would suggest based on this situation. The chart of the patient must available if case the physician ask…

Words 323 - Pages 2

The Head to Toe Assessment Essay

The Head to Toe Assessment Principles of Assessment for RN’s Edward is a 45 year old male who is present today for his Annual Physical Examination. He is asymptomatic and has no complaints. Subjective: History: The patient has a history of Chicken Pox at 5 years old. He has been a smoker for 25 years and currently smokes 2 packs a day. He consumes alcohol daily 2-4 glasses of wine. He reports of history of depression and anxiety 3 years ago after separating from his wife. His is not currently…

Words 2236 - Pages 9

Head To Toe Assessment Case Study

assessment in a head to toe sequence, as I would an adult. I engaged in conversation with him during the assessment and it helped the patient establish a trusting relationship. I asked questions and allowed him to explain to me why he was in the hospital. We talked…

Words 1434 - Pages 6

Essay about Pelvis and Rotate Thigh

Atziri Mendoza Anatomy, period D Assignment 2 15 March 2013 Questions 11.19, 11.20, 11.21 MUSCLES OF THE GLUTEAL REGION THAT MOVE THE FEMUR Iliopsoas & Psoas major * ORIGIN: Transverse processes and bodies of lumbar vertebrae. * INSERTION: With iliacus into lesser trochanter of femur. * ACTION: Psoas major and iliacus muscles acting together flex thigh at hip joint, rotate thigh laterally, and flex trunk on hip as in sitting up from supine position. * INNERVATION: Lumbar…

Words 1316 - Pages 6

Life Stage Essay

muscles and bones. At weeks 6 to 7 is the stage that most people realise that they are actually pregnant. The embryo is usually 8mm head to toe and the heart should be beginning to beat. Both the heart and brain are developing, while the skin is thickening at where the eyes and ears are going to be. At week 7 the embryo slightly increases to 10 mm head to toe. This measurement is called the ‘crown-rump length’. At weeks 8 to 9 the face of the baby will be slowly forming. A tongue would have…

Words 318 - Pages 2

Kill Bill, Volume 1:  Purging the Female Stereotype in Films Essay

stereotype in films. “Wiggle your big toe.” The toe doesn’t move. “Wiggle your big toe.” (Tarantino) It doesn’t move. The Bride played by actress Uma Thurman is really Beatrix Kiddo, but is known as Black Mamba as well as Arlene Machiavelli; her real name is bleeped out during Kill Bill, Volume 1 as she recounts the situation which led her to being in the back of a vehicle in a hospital parking lot with her legs in a state of atrophy whispering, “wiggle your big toe.” As she begins recounting the…

Words 1013 - Pages 5

Night In The Night: Love And The No-Man's Night

no-man's land For the longest time lady I need you darling Come on set the tone If you feel you're falling Won't you let me know Oh-Oh-Oh-Ooh-Oh Oh-Oh-Oh-Ooh-Oh If you love me come on get involved Feel it rushing through you from your head to toe Oh-Oh-Oh-Ooh-Oh Oh-Oh-Oh-Ooh-Oh Sing! Oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh [x2] Louder! Oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh Sing! Oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh-oh This love is a blaze I saw flames from the side of the stage…

Words 413 - Pages 2