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Head to Toe Assessment
Vital Signs:
Any signs of distress indicating a patient emergency
Patient's level of consciousness, speech, orientation
Eyes:
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Pupil size response to light
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Extraocular eye movements
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Accommodation
Mouth:
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Skin color around lips and tip of nose (checking for circumoral cyanosis)
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Mucous membranes for moisture (area between gums and cheek will stay
moist even with a mouth breather unless patient is dehydrated)
Neck for neck vein distention
Anterior chest
Heart Sounds:
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Aortic |
Pulmonic |
Tricuspid |
Mitral |
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Location |
2nd intercostal space at the right sternal border |
2nd intercostal space at the left sternal border |
4th or 5th intercostal space at the left lower sternal border |
5th intercostal space near the left midclavicular line |
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Loudest sound |
S2 |
S2 |
S1 |
S1 |
Listen to Heart Sounds:
(N170 Students are responsible for normal heart sounds ONLY)
Breath Sounds
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Vesicular
low, breezy soft sounds heard over the periphery of the lung fields
Bronchovesicular
Equal inspiration and expiration, medium quality, heard over the mainstem bronchi
Bronchial
Course, loud sound heard over the trachea
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Some links to listen to breath sounds:
Abdomen
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Observe the abdomen for symmetry, contour, movement
Listen in each of the four quadrants for bowel tones.
Lightly palpate if indicated (tenderness, bladder distention)
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Steps to auscultate bowel sounds:
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Place diaphragm of stethoscope LIGHTLY over each four quadrants room should be quiet.
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Listen for repeated gurgling or bubbling sounds in EACH quadrant (minimum of once
in 5 to 20 seconds). If patient has an
N/G suction you may need to clamp while listening.
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Describe sounds as normal (active), hyperactive, hypoactive, or absent. (Listen
5 minutes over each quadrant before deciding bowel sounds are absent.)
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Nurse Alert: If aortic bruit is auscultated,
suggesting presence of an aneurysm, stop assessment and notify physician immediately
- check patient's H & P too.
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Normal bowel sounds occur irregularly every 5 to 15 seconds. Common
for bowel sounds to be hypoactive postoperatively
for 24 hours or more (esp. following abdominal surgery).
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Absence of sounds cessation of gastric motility
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Hyperactive (not related to hunger or recent meal) diarrhea or early intestinal
obstruction.
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Hypoactive or absent paralytic ileus or peritonitis
Upper Extremities: CMS checks Circulation:
Capillary refill, radial pulses
Motion/Sensation:
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Hand grasps
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Push/pull
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Straight arm raise
Lower Extremities: CMS checks
Circulation: Capillary refill, posterior tibial and dorsalis pedis
pulses
Motion/Sensation:
Posterior Chest
In listening to breath sounds, while listening to either the anterior
or posterior chest, be sure to auscultate the right middle lobe on the right lateral
side of the chest.
Videos:
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(9 minutes, 25 seconds)
Clinical Assessment: Presentation for completing a bedside assessment. Loretta Thrape, NP,MSN, BSN, (faculty) Leslie, SC | |
(2 minutes, 30 seconds)
Clinical Assessment-Out Takes: funny segments during filming | |
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