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> nursing student checklist head to toe assessment
nursing student checklist head to toe assessment
General Assessment
Introduce yourself to the patient
Confirm the patient's identity
Observe the patient's general appearance and behavior
Assess the patient's level of consciousness
Check the patient's vital signs (temperature, pulse, blood pressure, respiratory rate, oxygen saturation)
Head and Neck Assessment
Inspect the patient's head and scalp
Palpate the patient's head for any abnormalities
Inspect the patient's face for symmetry and any abnormalities
Inspect the patient's eyes, ears, nose, and mouth
Assess the patient's neck for range of motion and any abnormalities
Cardiovascular Assessment
Inspect and palpate the patient's chest for any abnormalities
Auscultate the patient's heart sounds (rate, rhythm, and quality)
Palpate the patient's peripheral pulses
Assess the patient's capillary refill
Respiratory Assessment
Inspect the patient's chest for any abnormalities
Auscultate the patient's lung sounds (rate, rhythm, and quality)
Assess the patient's respiratory effort and breathing pattern
Measure the patient's oxygen saturation
Assess the patient's respiratory rate and depth
Palpate the patient's chest for any tenderness or abnormal masses
Evaluate the patient's cough and sputum production
Assess for any signs of respiratory distress or difficulty breathing
Abdominal Assessment
Inspect the patient's abdomen for any abnormalities
Auscultate the patient's bowel sounds
Palpate the patient's abdomen for tenderness, masses, or organomegaly
Check for any signs of distention or hernias
Neurological Assessment
Assess the patient's level of consciousness and orientation
Test the patient's cranial nerves
Assess the patient's motor and sensory function
Test the patient's reflexes
Evaluate the patient's coordination and balance
Assess the patient's gait and mobility
Perform a brief mental status examination
Test for signs of abnormal movements or tremors
Evaluate the patient's speech and language abilities
Integumentary Assessment
Inspect the patient's skin for color, temperature, moisture, and integrity
Palpate the patient's skin for texture, turgor, and edema
Check for any lesions, rashes, or wounds
Assess the patient's pressure ulcer risk
Musculoskeletal Assessment
Assess the patient's range of motion in all joints
Palpate the patient's muscles and joints for tenderness, swelling, or deformities
Check for any signs of muscle weakness or atrophy
Observe the patient's gait and balance
Psychosocial Assessment
Ask the patient about their emotional well-being and stress levels
Assess the patient's support system and coping mechanisms
Check for any signs of anxiety, depression, or other mental health concerns
Address any cultural or spiritual considerations
Summary and Documentation
Summarize your findings in an organized and concise manner
Document your assessment findings accurately and thoroughly
Communicate any abnormal findings to the appropriate healthcare provider
Plan and prioritize nursing interventions based on your assessment results
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