![]() Inspect nails for consistency, colour, and capillary refill.Ĭheck for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.Palpate skin for temperature, moisture, and texture.Inspect for lesions, bruising, and rashes.Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9. Unusual findings should be followed up with a focused neurological system assessment. Complete necessary focused assessments.Īlterations may reflect neurologic impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness.Apply principles of asepsis and safety.Assess ABCCS (airway, breathing, circulation, consciousness, safety)/suction/oxygen/safety.Use appropriate listening and questioning skills.Be organized and systematic in your assessment.Confirm patient ID using two patient identifiers (e.g., name and date of birth).Checklist 17: Head-to-Toe Assessment Disclaimer: Always review and follow your hospital policy regarding this specific skill. Any unusual findings should be followed up with a focused assessment specific to the affected body system.Ī physical examination involves collecting objective data using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. This could be when a client is first admitted to a hospital, at the beginning of a nursing shift, whenever there is a significant change in a patient’s condition, or following a regular schedule of assessments based on facility policy or monitoring guidelines.A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. Head-to-toe assessments are typically done whenever healthcare personnel need to take stock of a client’s overall health status. ![]()
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