Latest NSG 1400 Head to toe (Answer Guide)
Study online at https://quizlet.com/_j6xvwm
1. Standard steps Provide for privacy
Introduce myself using 2 identifiers
Confirm pt name and dob
Explain procedure
Position client (raise bed and head of bed)
2. General survey Age
Sex/gender orientation
Race
Level of consciousness and orientation
Hygiene and grooming
Mood and affect
Cultural background or ethnic origin
Spiritual or religious practices
Speech/communication needs
Safety concerns
3. Intravenous Patency
catheters Assess site for redness, swelling, pain, or warmth
Inspect dressing, dry and intact
Verification of order
4. vital signs, Bp
height, weight Temp
Respiratory rate
Pulse ox
Pulse
Height
Weight
5. Pain Asses pain on numeric pain scale
Acute or chronic
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, NSG 1400 Head to toe
Latest NSG 1400 Head to toe (Answer Guide)
Study online at https://quizlet.com/_j6xvwm
Location
Does it radiate?
Does it come and go or is it consistent?
Nonverbal cues
Does anything make it better/worse?
6. Head Symmetry
Inspect for nodules, lesions, infestations, hair distribution and texture
7. Eyes Ask about contacts or glasses use
Measure pupil size
Assess pupils for roundness
Assess pupils for reactivity to light
Assess pupils for accommodation
8. Ears Ask about hearing aids
Inspect ear for redness, tenderness, or drainage
9. Nose Inspect for drainage or lesions
10. Mouth Inspect oral hygiene
Mucous membranes (pink and moist)
Tongue midline
Lesions
Dentition
11. Neck Palpate carotid arteries (one at a time)
Auscultation of carotid arteries with small side of stethoscope
Palpate trachea midline
Inspect for JVD
12. Chest Symmetry and shape
Assess for use of accessory muscles
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