STANDARD APPROACH TO PATIENT CARE (HEAD TO TOE ASSESSMENT)

Cranial Nerve VI

Abducens (look side to side)

Cranial Nerve XI

Accessory (shrug shoulders and turn head side to side)

Cranial Nerve VII

Facial (smile)

Preparing Patient

· *Introduces self to patient. AIDET · Identifies patient: reads wristband, and asks patient to state his name.* Follows agency protocol. · Explains the procedure to patient, including what he will feel and need to do (e.g., "You will need to lie very still"). · Provides privacy (e.g., asks visitors to step out, drapes patient). · Uses good body mechanics: positions bed or treatment table to a working level; lowers the near side rail.

CARDIOVASCULAR ASSESSMENT

1) Auscultated the heart in all four anatomic sites: aortic, pulmonic, tricuspid, and apical 2) Palpates the peripheral pulses on both sides of the client's body individually and simultaneously (except carotid pulse) to determine the symmetry of the pulses 3) Assessed peripheral leg veins for signs of phlebitis a. Inspected the calves for redness and swelling over vein sites b. Palpated the calves for firmness or tension of the muscles the presence of edema over the dorsum of the foot, and areas of localized warmth 4) Assessed for edema. If present, note location, color, temperature, shape and the degree to which the skin remains indented or pitted when pressed by a finger. Measure circumference of extremity if needed 5) Inspected the skin of the hands and feet for color and temperature or skin changes 6) Assessed the adequacy of arterial flow using the capillary refill test

MUSCOLSKELETAL ASSESSMENT

1) Inspected the muscles for size, comparing the muscles on one side of the body to the same side muscles on the other side, noting any discrepancies and measure with a tape measure if discrepancies present 2) Inspected for tremors 3) Tested muscle strength comparing the right with the left side 4) Assessed joint range of motion 5) Inspected joints for swelling, palpating for tenderness, swelling and presence of nodules 6) Observe client ambulating - note any irregularities in gait, balance, coordination, strength

VITAL SIGNS

1) Takes temperature using temporal, tympanic, oral, or forehead scanner thermometer. Record the value 2) Counts radial pulse for 30-60 seconds. Records beats per minute. Able to verbalize that an apical pulse would be obtained for a full 60 seconds if any abnormalities or irregularities in hear rate or rhythm 3) Counts respirations for 30 to 60 seconds and records value. Verbalizes that if any irregularities present, would count for a full 60 seconds. 4) Manually auscultates systolic and diastolic blood pressure using cuff, sphygmomanometer, and stethoscope. Records value 5) Applies pulse oximeter, obtains and records value 6) Able to verbalize normal values for vital signs and steps that would be taken for values outside the norm (i.e. reassess, validate data, report to the provider)

RESPIRATORY ASSESSMENT

1. Auscultated the chest using the diaphragm of the stethoscope Used a systematic zigzag approach to auscultate Asked the client to take slow, deep breaths through the mouth and listened at each point to the breath sounds during a complete inspiration and expiration Compared findings at each point with the corresponding point on the opposite side of the thorax 2. Observed or palpated and counted respiratory rate (can be done during vital signs assessment) 3. Observed depth, rhythm, and character of respirations

SKIN ASSESSMENT

1. Inspects skin color, including areas not usually exposed to sun, under natural light 2. Inspected for uniformity in color 3. Inspected, palpated, and described skin lesions. Applied gloves if open or draining lesions. 4. Described lesions according to location, distribution, color, configuration, size, shape, type or structure. Measured lesion. 5. Observed and palpated for skin moisture 6. Palpated skin temperature and compared the extremities using the back of the hand 7. Noted skin turgor (fullness or elasticity) by lifting and pinching the skin below the clavicle or on the forearm

NEUROLOGICAL/HEENT ASSESSSMENT

1. Observed the client's overall hygiene and grooming 2. Observed for signs of distress in posture or facial expression 3. Noted the client's attitude, affect/mood; assessed the appropriateness of the client's responses. 4. Determine orientation to time, place, person and situation; ask why the client is being evaluated 5. Assess cranial nerves II, III, IV, VI by testing PERRLA and visual tracking. Reports any abnormalities or extra ocular movement 6. Assesses cranial nerves V, VII and XII by asking client to smile, frown and stick out tongue. Reports any abnormalities or deviations. Observe client's ability to swallow and control oral secretions 7. Assesses cranial nerve XI by performing a shoulder shrug with resistance 8. Asks client if they have experienced any recent change in ability to smell or taste, or any acute changes in vision or hearing 9. Perform fine and gross motor assessment of upper and lower extremities 10. Assess oral and nasal mucosal membranes, noting color, moisture, drainage 11. Assess dentition noting abnormalities 12. Inspects scalp, outer ear, face and neck - noting any masses, skin changes, pain, bony deformities, wounds or drainage 13. Assess pain level, using Numeric Pain Scale Tool

GASTROINTESTINAL/GU ASSESSMENT

Assisted the client to a supine position, with arms placed comfortably at the sides with the knees slightly flexed Examines the abdomen in this order: inspection, auscultation, and palpation a. Inspects for skin integrity, size, symmetry and contour b. Observes the condition of the skin and skin color, lesions, scars, or striae c. Auscultates for bowel sounds, using the diaphragm of the stethoscope; listens for 5 minutes in each quadrant before concluding that bowel sounds are absent d. Palpates the abdomen with light pressure, pressing down 1-2 cm in a rotating motion; identifies characteristics, tenderness, muscular resistance, and turgor Determines last bowel movement; size, shape, color - is this client's normal bowel movement appearance Determines client's ability to void, asks about any changes in urinary elimination patterns, pain with urination, urine color/clarity

Cranial Nerve IX

Glossopharyngeal (swallow)

Cranial Nerve XII

Hypoglossal (stick tongue out)

Cranial Nerve III

Oculomotor (motor) (upward, medial, downward, up and in)

Cranial Nerve I

Olfactory (smell)

Cranial Nerve II

Optic - vision

PERRLA DEFINITION

Pupils Equal Round React to Light and Accommodation

Cranial Nerve V

Trigeminal (touch forehead and cheek and clench teeth)

Cranial Nerve VI

Trochlear (down and in)

Cranial Nerve X

Vagus (say "ah")

Cranial Nerve VIII

Vestibulcochlear (hearing and balance) (snap fingers beside each ear. have them stand on one foot)

After the Procedure

· *Leaves patient in a comfortable, safe position with the call light within reach.* · If patient is in bed, returns the bed to the low position and raises the side rail (if patient requires this precaution). · Disposes of supplies and materials according to agency policy. · Washes hands again before leaving the room. · Documents that the procedure was done; documents patient's responses.

Before Approaching Patient

· *Washes hands; dons procedure gloves, if needed.* · Gathers supplies and equipment before approaching patient. · Obtains assistance, if needed (e.g., to move a patient).

During the Procedure

· Washes hands before touching patient, before gloving, and after removing gloves. · Observes universal precautions (e.g., dons and changes procedure gloves when needed). · Maintains sterility when needed. · Maintains correct body mechanics. · Provides patient safety (e.g., keeps side rail up on far side of the bed). · Continues to observe patient while performing the procedure steps and pauses or stops the procedure if patient is not tolerating it. · Performs the procedure within an acceptable period of time.