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Head to-toe assessment review
1.
2. What equipment would you need to perform your head-to-toe assessment?
Answer: Stethoscope, Blood Pressure (BP) cuff, watch, and pen light
3. Name four (4) Patient safety goals that should be considered when
performing a head-to-toe exam?
Answer:
Patient identification standard
Effective communication among healthcare provider
Attention to standard precautions
Medication safety alert (Known allergies)
4. What is the advantage of performing a head-to-toe assessment by region
rather than system?
Answer: To minimizes patient position change
5. What is best for auscultation and what is the purpose of a bell and
diaphragm?
Answer: A combination stethoscope of a bell and diaphragm
The bell is best for detecting low-pitched sounds such as rhonchi (a
low-pitched breath sound that occur when air tries to pass through
bronchi tubes that contains fluid or mucus, a condition for
bronchitis.
The diaphragm is best for high-pitched sounds such as crackles and
wheezing; crackles occurs if the small air sacs (alveoli) in the lungs
fill with fluid and there is no air movement in the sacs for breathing,
the air sacs fill with fluid is a condition for pneumonia or heart
failure. Wheezing occurs when the bronchial tubes become
inflamed and narrowed a condition for Asthma (grasping for air).
6. When performing palpation, which part of the hand is best for detecting
temperature changes? Vibrations? Pulsation?
Answer:
Temperature, dorsal (back) aspect of the hand
Vibration, balls of hands
Pulsations, finger pads
10. Gasper M. L. & Dillon P. M. (2012). Clinical Simulations for Nursing
Education. www.FADavis.com
The Joint Commission National Patient Safety Goals Hospital
Program.
http://www.jointcommision.org/generalpublic/NPSG10_npsgs.htm
SBAR Technique for Communication: A situational briefing
modelpublished by the Institute for Healthcare Improvement.
http://www.ihi.org/IHI/Topics/PatientSafety/SafetyGeneral/Tools/S
BARTechniqueforcommunicationasituationalBriefing.htm