Head to toe assessment Questions and Correct
Answers
when an assessment would be done
✓ ~~~ beginning of each shift
✓ weekly or monthly in long term care
✓ whenever a change occurs
✓ whenever you as the nurse think its necessary
what is a head to toe assessment
✓ ~~~ a physical assessment of each body system that offers objective information
about the patient
✓ the skills of assessment enable us to detect subtle as well as obvious changes in the
patients health status
✓ to gain the patients cooperation during assessment we need to explain why it is
necessary
preparing for assessment
, ✓ ~~~ bedside reporting
✓ look at your patients chart/computer
✓ know their diagnosis, allergies, recent labs, HX, chief c/o
✓ provide privacy
✓ ensure warm comfortable temperature in room
✓ tell patient what to expect
✓ drape areas that dont need to be exposed
✓ use a relaxed voice and facial expression
✓ have a 3rd person of the patients gender present when assessing genitalia to protect
yourself from being accused of doing anything unethical
✓ with children allow them to play with and visualize equipment prior to assessing to
facilitate cooperation
✓ when finished ask patient if they have any questions or concerns
✓ when asking questions don't be judgemental making sure you don't sound
accusatory
✓ ask open ended questions to foster communication
✓ adolescents do have the right to confidentiality
✓ elderly patients will take extra time to assess
cultural awareness
✓ ~~~ need to make yourself aware of cultural differences and practices in the
population you will be working with
Hispanics are usually very modest
Asian/ Pacific islanders avoid touching
you will have to observe and see what your patient is comfortable with
respect cultural beliefs
Setting Priorities when assessing
, ✓ ~~~ generally we assess from head to toe direction but if a patient presents with a
specific problem or complaint we assess that area first and them when resolved or
assessed we return to the head to toe pattern
if going to do something painful save it for the last thing in that area
your going to inspect, palpate, percuss, auscultate in that order except with the
abdomen
always follow infection control standards
check for latex allergies
record your assessment asap
when you assess you are gathering initial data or comparing to previous shift
an Registered nurse must do the initial admission assessment
✓ ~~~ when assessing note both your patients verbal and nonverbal cues
assessment techniques
✓ ~~~ Inspection
Palpation
Percussion
Auscultation
olfaction
inspect
Answers
when an assessment would be done
✓ ~~~ beginning of each shift
✓ weekly or monthly in long term care
✓ whenever a change occurs
✓ whenever you as the nurse think its necessary
what is a head to toe assessment
✓ ~~~ a physical assessment of each body system that offers objective information
about the patient
✓ the skills of assessment enable us to detect subtle as well as obvious changes in the
patients health status
✓ to gain the patients cooperation during assessment we need to explain why it is
necessary
preparing for assessment
, ✓ ~~~ bedside reporting
✓ look at your patients chart/computer
✓ know their diagnosis, allergies, recent labs, HX, chief c/o
✓ provide privacy
✓ ensure warm comfortable temperature in room
✓ tell patient what to expect
✓ drape areas that dont need to be exposed
✓ use a relaxed voice and facial expression
✓ have a 3rd person of the patients gender present when assessing genitalia to protect
yourself from being accused of doing anything unethical
✓ with children allow them to play with and visualize equipment prior to assessing to
facilitate cooperation
✓ when finished ask patient if they have any questions or concerns
✓ when asking questions don't be judgemental making sure you don't sound
accusatory
✓ ask open ended questions to foster communication
✓ adolescents do have the right to confidentiality
✓ elderly patients will take extra time to assess
cultural awareness
✓ ~~~ need to make yourself aware of cultural differences and practices in the
population you will be working with
Hispanics are usually very modest
Asian/ Pacific islanders avoid touching
you will have to observe and see what your patient is comfortable with
respect cultural beliefs
Setting Priorities when assessing
, ✓ ~~~ generally we assess from head to toe direction but if a patient presents with a
specific problem or complaint we assess that area first and them when resolved or
assessed we return to the head to toe pattern
if going to do something painful save it for the last thing in that area
your going to inspect, palpate, percuss, auscultate in that order except with the
abdomen
always follow infection control standards
check for latex allergies
record your assessment asap
when you assess you are gathering initial data or comparing to previous shift
an Registered nurse must do the initial admission assessment
✓ ~~~ when assessing note both your patients verbal and nonverbal cues
assessment techniques
✓ ~~~ Inspection
Palpation
Percussion
Auscultation
olfaction
inspect
