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Basic head to toe assessment

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Basic head to toe assessment

Publicada em: Saúde e medicina
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Basic head to toe assessment

  1. 1. Christi Scott, RNChristi Scott, RN
  2. 2.  By theend of thispresentation, studentswill be ableto:   Demonstratewhereto listen for an apical pulse..  Demonstrateproper techniquefor listening to breath sounds.  Demonstratehow to assessfor pitting edema.  List thethreewaysto assessthepatient’s mental statusand orientation. 2
  3. 3.  Knock and introduceyourself.  Wash your handsand don glovesprior to touching thepatient.  Establish rapport by using eyecontact.  Sit at thelevel of thepatient if possible.  Explain all proceduresto thepatient prior to performing them. 3
  4. 4. Vital Signs PulseRate, Strength, Regularity Temperature________ Oral, Rectal, Tympanic Respiration_______________ B / P_________ Pain Assessment _________________ Oxygen saturation ________________ 4
  5. 5. Assessing ForPain (PQRST method) P– Provokes, palliativemeasure Q – Quality (describe) R – Region, radiate? S– Severity, on ascaleof 0 - 10 T – timing, when did it start?How long doesit last? 5
  6. 6. Orientation – time, person, place, reason Can you tell me your name? _______________________ Can you tell me whereyou are? ____________________ Do you know what today'sdateis? __________________ Pupil Check ( PERRLA ) Pupils, Equal, Round, React to light, Accommodate Sluggish ( ) No Change( ) Brisk ( ) Normal ( ) Accommodation Yes( ) No ( ) 07/27/14Free Template from www.brainybetty.com 6
  7. 7. Neck Veins Patient at 45 degreeangle( ) Neck VeinsFlat ( ) Distended ( )  Neck veinsshould bechecked by having thepatientNeck veinsshould bechecked by having thepatient sit at a45 degreeangle. In thisposition, thejugularsit at a45 degreeangle. In thisposition, thejugular veinsshould beflat.veinsshould beflat.  Distended neck veinsat 45 degreesarean indicator ofDistended neck veinsat 45 degreesarean indicator of over hydration or fluid overload.over hydration or fluid overload. 7
  8. 8. Edema, or fluid in thetissuestendsto go to dependent areasof thebody. Thismay bethehands, feet or sacrum. To check for edemapush your finger down on thefoot over thedistal end of thetibiaand observefor indentation or pitting.
  9. 9. 1+ slight pitting, no visible distortion, disappears rapidly 2+ somewhat deeper pit than 1+, no readily detectable distortion, disappears in 10-15 sec. 3+ pit noticeably deep, may last more than a minute; the dependent extremity looks fuller and swollen. 4+ pit very deep, lasts 2-5 min; dependent extremity is grossly distorted.
  10. 10. Heart Tones Apical Pulsewith Stethoscope Rate?_____________ Rhythm ?___________ Clarity of Sounds?_________ Abnormal ? Explain ! ____________________________ 07/27/14Free Template from www.brainybetty.com 10
  11. 11. 11 Ape(Apical and Pulmonic) To(Tricuspid) Men(Mitral)
  12. 12. Heart tonesarechecked by listening to theapical pulsefor atotal of one minute. Thispulseisauscultated with thebell of thestethoscope. Check theapical pulsefor rate, rhythm, and clarity of thesoundsof theS1 and S2 otherwiseknown as"lub and dub". Any abnormalitiesshould bereported.
  13. 13. Bilateral Pulse Checks  ( Radial Pulses ) - Rate, Strength, Regularity Right_____________ Left______________  ( Pedal Pulses – DP/PT) - Top of Foot Right Foot __________ Left Foot ____________  ( Capillary Refill ) - On fingersor toes3 secondsor less Right Fingers( ) sec. Left Fingers( ) sec. Right Toes( ) sec. Left Toes( ) sec. 13
  14. 14. DorsalisPedis (To locatepulsedraw astraight line back from thepatientsgreat toeto the middleof thedorsum of thefoot)
  15. 15. 16
  16. 16. Breath Sounds  Assessanterior and posterior and from sideto side, left to right lobeusing thediaphragm of the stethoscope.  Havepatient takedeep breaths, do not move stethoscopeto rapidly to avoid hyperventilation.  Havethepatient takedeep breathsin and out of their mouth asnosebreathing can createair turbulence that may alter thesounds.  Breath soundsshould beclear bilaterally with good air flow. 17
  17. 17. Normal breath sounds Bronchial sounds - Pitch: High. Intensity: Loud, predominantly on expiration. Normal findings: A sound likeair blown through ahollow tube Bronchovesicularsounds - Pitch: Moderate. Intensity: Moderate. Normal findings: A blowing sound heard over airwayson either sideof sternum, at angleof Louis, and between scapulae Vesicularsounds - Pitch: High on inspiration, low on expiration. Intensity: Loud on inspiration, soft to absent on expiration. Normal findings: Quiet, rustling sounds, heard over periphery
  18. 18. ADVENTITIOUSSOUNDS  FineCrackles(Rales) Over lung fieldsand airways; heard in lung basesfirst with pulmonary edema Moreaudibleduring inspiration Cause: Moisture, especially in small airwaysand alveoli SoundslikeRiceCrispiesCereal.  Rhonchi / CoarseCrackles Heard larger airways. Morepronounced during expiration Caused bronchospasm or secretions Soundslikerattling, usually louder and lower-pitched than finecrackles. Clearswith coughing.
  19. 19.  Wheezes Heard over lung fieldsand airways Inspiration or expiration Caused bronchospasm Soundslikeahigh pitched whistle  Pleural Friction Rub Heard at front and sideof thelung fields Inspiration Causeby theinflamed parietal and visceral pleural surfaces rubbing together. Soundslikegrating or squeaking.
  20. 20. Bowel Sounds  Assessall 4 quadrants, do not touch stomach before auscultation, asit may disrupt normal sounds. If irregular,  1 minuteassessment on each quadrant to accurately record no bowel soundspresent.  ( Stomach ) – Inspect and palpatefor condition Soft ( ) Hard ( ) Distended ( ) Other  RUQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )  RLQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )  LUQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )  LLQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( ) 22
  21. 21. Ask the patient about: Urgency, burning, incontinenceand pain. Assess: Catheter, drainage, urineoutput. 23
  22. 22. Skin  Skin Turgor - 1 to 3 second return on thedorsum of the hand.  Skin Color - Check on insideof Lip or Conjunctiva Lip ( ) Conjunctiva( ) Pink ( ) Pale( ) Jaundice( )  Skin Temperature- Useback of hand to check Hot ( ) Warm ( ) Cool ( ) 24
  23. 23. 0 No defection of muscular contraction 1 A barely detectable flicker or trace of contraction with observation or palpation 2 Active movement of body part with eliminations of gravity 3 Active movement against gravity only and not against resistance 4 Active movement against gravity and some resistance 5 Active movement against full resistance without evident fatigue (normal muscle strength)

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