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Final Head to Toe
Question | Answer |
---|---|
What is the first phase of the HTT? | Introduction |
What are the 5 steps of the Introduction phase of the HTT? | 1. AIDET 2. Hand hygiene w/ verbalization 3. Identifiers: Name, DOB 4. Privacy & inside voice 5. Adjust bed to working height |
What is the second phase of the HTT? | Interview/HHQ |
What are the 5 main questions during the Interview/HHQ phase of the HTT? | 1. pain level 2. history of respiratory issues 3. change in BM 4. history of heart issues 5. recent dizziness |
What is the order of the 10 phases of the HTT? | 1. Introduction 2. Interview/HHQ 3. Mental status 4. General appearance/HEENT/SHN 5. Respiratory system 6. Cardio system 7. Abdomen 8. Neuro/MSK 9. Risk scales 10. Safety & exit behaviors |
Sample documentation for Interview/HHQ phase of the HTT? | "patient reports pain level of 0, no recent respiratory/heart problems, no change in BM, denies dizziness" |
What is the third phase of the HTT? | Mental Status |
Sample documentation for mental status appearance? | "dressed appropriately for weather & situation, well-groomed w/ proper hygiene evident" |
What are the 4 steps of the Mental Status phase of the HTT? | 1. Appearance 2. Behavior 3. Cognition 4. Speech |
How to decipher cognition? | ask about person, place, time, situation |
Sample documentation for behavior & cognition? | awake, alert, and oriented x4 |
Sample documentation for speech? | "speech clear" |
Sample documentation for general appearance? | "body position is relaxed & sitting upright, no obvious physical deformities" |
What are the 8 steps of the GA/HEENT/SHN phase of the HTT? | 1. Body position & obvious deformities 2. Respiratory effort 3. Head shape & facial appearance 4. Hair, ears, nose, teeth appearance 5. Eyes, ear, nose, mouth symmetry 6. CN II, IV, VI 7. skin color 8. skin turgor |
What is the fourth phase of the HTT? | GA/HEENT/SHN |
Sample documentation of respiratory effort? | "unlabored respiratory effort" |
Sample documentation for head shape & facial appearance? | "Normocephalic, face symmetrical & expressive bilaterally" |
Sample documentation for hair, ears, nose, & teeth appearance? | "Hair neat & well-groomed, nose straight/symmetrical and unblemished, 32 teeth intact w/ normal ivory color, ears symmetrical bilaterally w/ no lesions" |
Sample documentation for eyes, ears, nose, & mouth symmetry? | "eyes, ears, nose, mouth all symmetrical" |
Sample documentation for CN III, IV, VI, & XI? | "Oculomotor, Trochlear, Abducens intact (PERRLA); Spinal accessory intact" |
Sample documentation for skin color? | "pink lips, no cyanosis, no lesions/scars/rashes, brown skin tone, no abnormal pigmentation, skin warm & soft & dry, tattoos right lateral ankle (2 in long) & right inner wrist (1 in long)" |
How to check skin turgor? | pinch skin & watch how it snaps back |
Sample documentation for skin turgor? | "skin recoils rapidly when pinched" |
What is the fifth phase of the HTT? | Respiratory |
What are the 5 steps of the Respiratory phase of the HTT? | 1. Oxygen supply 2. Thoracic shape 3. Respiratory rate 4. Anterior 6 breath sounds 5. Posterior 8 breath sounds |
How many auscultation points for breath sounds are on the anterior chest? | 6 locations |
How many auscultation points for breath sounds are on the posterior chest? | 8 locations |
Sample documentation for anterior breath sounds? | "anterior breath sounds are clear bilaterally" |
Sample documentation for posterior breath sounds? | "posterior breath sounds are clear bilaterally" |