Busy. Please wait.
or

show password
Forgot Password?

Don't have an account?  Sign up 
or

Username is available taken
show password

why


Make sure to remember your password. If you forget it there is no way for StudyStack to send you a reset link. You would need to create a new account.
We do not share your email address with others. It is only used to allow you to reset your password. For details read our Privacy Policy and Terms of Service.


Already a StudyStack user? Log In

Reset Password
Enter the associated with your account, and we'll email you a link to reset your password.

Remove ads
Don't know
Know
remaining cards
Save
0:01
To flip the current card, click it or press the Spacebar key.  To move the current card to one of the three colored boxes, click on the box.  You may also press the UP ARROW key to move the card to the "Know" box, the DOWN ARROW key to move the card to the "Don't know" box, or the RIGHT ARROW key to move the card to the Remaining box.  You may also click on the card displayed in any of the three boxes to bring that card back to the center.

Pass complete!

"Know" box contains:
Time elapsed:
Retries:
restart all cards




share
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.

  Normal Size     Small Size show me how

Stack # 1315706

Head to Toe Assessment Checkoff

TermDefinition
NEURO/SENSORY - LOC Alert & Oriented X ________ 1)Person 2)Place 3)Time 4)Situation Lethargic/Drowsy/Confused/Forgetful/Unresponsive Sensations WNL Other ______________________
SPEECH/PUPILS/COMMUNICATION Clear/Understandable/Slurred/Nonverbal/Aphasia PERRL (L)___ (R)___ Coherent Conversation/Able to Grasp Ideas/Answers Questions Appropriately/Follows Instructions Other Obs.______________________
VISION/HEARING Vision WNL/Vision Impaired ___________ Hearing WNL/Hearing Impaired_____________ Other Obs._________________________
PAIN Pain Level _______ Location ________________ Intervention ___________________ Relief-Post Intervention Pain Level ______ Other Obs._______________________
CARDIOVASCULAR Heart Rate ____ Regular Irregular B/P ____/_____ Pulses-Present/Absent/Strong/Weak RRP-P/A/S/W LRP-P/A/S/W RPP-P/A/S/W LPP-P/A/S/W Nail Beds Pink CRT </> 3 sec Edema-Pitting Loc/Rating Non-Pitting Loc/Rating
RESPIRATORY Respiration Rate ___ Regular/Even/Unlabored/Labored/Shallow/Rapid O2 Sat ___% SOB (described) Breath Sounds & Loc - Clear/Equal, Rhonchi,Wheezes/Crackles Decreased or Diminished Cough Present - Y/N Productive/NonProductive Sputum____
GASTROINESTINAL Bowel Sounds: WNL(ActiveX4) Hypoactive/Hyperactive/Absent Abdomen: Soft/Firm/Hard/Distended/Tender LBM (described) ___________
DIET NPO/(diet) _________ Tolerates Well/Nausea/Vomiting(describe emesis) Dysphagia - Aspiration Precautions Tube Feeding ______ml/hr % of meals (B)_____(L)_____(D)______ Adequate/Inadequate Intake
RENAL/URINARY Voiding - Without Complaints/Dysuria/Frequency/Burning Continent/Incontinent Adequate/Inadequate Output Catheter Type ________ Patent&Draining _____ Color_____ Clarity_______ Sediment
MUSCULOSKELETAL (1st card) MAE Activity: Tolerates Well/Fatigue Activity: Amb per Self/Amb w/assist X____ Transfers per Self/Tranfers w/assist X___ Gait: Steady/Unsteady Assistive Devices___ Muscle Tone Normal/Fair/Poor/Flaccid RUE/RLE/LUE/LLE
MUSCULOSKELETAL (2nd card) Movement(normal/limited)-RUE/RLE/LUE/LLE Strength(strong or weak)-RUE/RLE/LUE/LLE ROM: Full/Limited/Passive (describe) Immobile (describe) ADL’s Independent/Total/Assist
SKIN Color - Pale/Pink/Ruddy/Grey/Jaundice/Cyanosis Skin Turgor - Normal/Sluggish/Loose Skin - Warm/Dry/Cool/Diaphoretic Skin Condition - Fragile/Thin/Intact/Impaired Mucus Membranes - Moist/Pink/Intact Redness/Rash/Wounds
PSYCHOSOCIAL Cooperative/Uncooperative Behavior Appropriate/Inappropriate Coping Well/Depression/Anxious
PRIOR TO ENTERING ROOM - WHAT DO YOU DO? Gather equipment needed for assessment a.Stethoscope b.Appropriate sized blood pressure cuff c.Pulse Oximeter d.Penlite e.Thermometer f.Gloves
UPON ENTERING ROOM - WHAT DO YOU DO? a.**Perform hand hygiene b.Identify self c.**Identify patient d.**Verify Allergies e.Assure privacy f.**Explain what is about to occur g.Allow for patient questions h.Raise bed to comfortable working height i.Don gloves
PRIOR TO LEAVING THE ROOM - WHAT DO YOU DO? 1.Check equip: a.IV-solution/rate/site b.O2-setting/type c.Drains(including foley) 2.Survey envir. for safety 3.Reposition pt 4.Lowerbed 5.Raise approp. rails 6.Call light/belongings in reach 7.**Hand Hygiene 8.Gather/Remove equipment
Created by: prich57