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Head To Toe Assessment

This document outlines the steps for performing a head-to-toe assessment. It examines the head, eyes, mouth, throat, neck, chest, abdomen, appendicular assessment including arms and legs, skin color, mental status including orientation and level of consciousness. The assessment checks for abnormalities in various body systems and functions like breathing, heart sounds, bowel sounds, reflexes, skin changes, orientation, and consciousness level.

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الأغا محمد زكارنة
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7K views

Head To Toe Assessment

This document outlines the steps for performing a head-to-toe assessment. It examines the head, eyes, mouth, throat, neck, chest, abdomen, appendicular assessment including arms and legs, skin color, mental status including orientation and level of consciousness. The assessment checks for abnormalities in various body systems and functions like breathing, heart sounds, bowel sounds, reflexes, skin changes, orientation, and consciousness level.

Uploaded by

الأغا محمد زكارنة
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Head to Toe Assessment

Head
Eyes: check sclera, conjunctiva,
accomodation, PERRLA
Mouth: pink, moist, without odor,
teeth alignment, number of teeth,
throat: redness, exudate, lesions

Neck
Alignment: flexibility
Vascular: palpate carotid pulsations,
listen for Carotid bruit
Bruit: swishing sound heard with
stethoscope at carotid artery.
Lymph nodes: palpate for swelling

Chest
Breathing: bilateral sounds,
inspiration and expiration, rales,
rhonchi, crackles
Heart Sounds:S1 and S2= lubb
dubb. Note rate, regularity rhythm
Note AP should be 1:2 ratio

Abdomen
Palpate for tenderness, guarding,
Listen to Bowel Sounds in all 4
quadrants. RU, RL, LU, LL
Note quality of sounds, hypoactive,
hyperactive, without sound

Appendicular Assessment
Arms: check for bilateral alignment,
note grip strength, as well as ability
to release grip
Note capillary refill in fingertips
Legs: Check for bilateral alignment,
note reflexes(Babinski) as well as
strength of flexion and
extension(gas pedal), varicose veins

Skin Color
Note any changes in complexion:
Jaundice
Cyanosis
Darker skinned patients may appear
pale instead of a bluish tint.

Mental Status
Orientation:
Name
Day of week
Date
Who is president
Situation: If other assessments are
negative.

Mental Status-Level of
Consciousness
Alert: aware of situation and
surroundings
Decreased LOC: somewhat awake,
easy to fall into sleep, may or may
not be aware of situation or
surroundings.
Unresponsive: no verbal, or physical
response to stimulation

THE

END

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