Head-to-Toe Assessment Demonstration

Introduction

• Presenter: Charlie
• Scenario: Nurse performing a head-to-toe assessment on a patient named Sarah.

Patient Identification

• Patient name: Sarah Smith
• Date of birth: November 22, 1979
• Nurse name: Carol

Initial Assessment

• No pain reported by the patient.
• Orientation check: Patient knows location (Rasmussen Hospital) and date (July 20th).

Memory Test

• Three words to remember: cat, boat, fish.

Head and Face

• Inspecting and palpating head.
• Checking cranial nerves II, III, IV, VI: Pupil response, eye movement.
• Checking cranial nerve V: Jaw movement.
• Checking cranial nerve VII: Facial expressions (smile, puff cheeks).

Ears, Nose, and Throat

• Inspecting ears and nose.
• Checking cranial nerves IX, X, XII: Swallowing and tongue movement.
• Checking cranial nerve XI: Shoulder shrug resistance.

Neck

• Trachea is midline.
• No Jugular Vein Distention (JVD).
• No swollen lymph nodes.

Chest and Lungs

• Inspecting and palpating the chest.
• Listening to lung sounds: Breathing in and out.
• Listening to heart sounds: Aortic, Pulmonic, Erb's point, Tricuspid, Mitral valves.

Abdomen

• Inspecting and auscultating abdomen starting from the right lower quadrant.
• Light palpation performed.
• Asking about last bowel movement and urinary issues.
• Sexual activity and menstrual history.

Upper Extremities

• Inspecting and palpating arms and elbows.
• Motor and sensory function: Hand squeeze, finger touch.
• Checking circulation: Radial pulse, capillary refill.

Lower Extremities

• Inspecting and palpating legs and joints.
• Checking for pedal edema, dorsalis pedis, posterior tibial pulses.
• Noting necrotic wounds.
• Motor function: Hand push and pull exercises.
• Reflex check: Babinski sign.

Back

• Inspecting for skin breakdown, especially on bony prominences and coccyx.
• Listening to lung sounds on the back.

Conclusion

• Verification of memory test: Patient remembers the words cat, boat, fish.
• Checking the Four P's: Pain, Potty, Position, and Possessions.
• Ensuring patient comfort and safety: Call bell and other needs within reach.
• Nurse will check back later.

Key Procedures Highlighted

• Cranial nerve assessment
• Inspection, palpation, auscultation techniques
• Importance of patient comfort and safety