{"id":269,"date":"2015-02-17T18:54:28","date_gmt":"2015-02-17T18:54:28","guid":{"rendered":"http:\/\/opentextbc.ca\/clinicalskills\/?post_type=chapter&p=269"},"modified":"2021-10-15T16:47:26","modified_gmt":"2021-10-15T16:47:26","slug":"2-2-head-to-toe-assessment-checklist","status":"publish","type":"chapter","link":"https:\/\/opentextbc.ca\/clinicalskills\/chapter\/2-2-head-to-toe-assessment-checklist\/","title":{"raw":"2.5 Head-to-Toe Assessment","rendered":"2.5 Head-to-Toe Assessment"},"content":{"raw":"A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient's hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient's overall condition. Any unusual findings should be followed up with a focused assessment<\/a> specific to the affected body system.\r\n\r\nA physical examination involves collecting objective data\u00a0using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take.\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n\r\n
<\/a>Checklist 17: Head-to-Toe Assessment<\/caption>\r\n
\r\n
Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/h5>\r\n<\/td>\r\n<\/tr>\r\n
\r\n
Safety considerations:<\/h5>\r\n
\r\n

Steps<\/h4>\r\n<\/td>\r\n

\r\n

Additional Information<\/h4>\r\n<\/td>\r\n<\/tr>\r\n

1. General appearance:\r\n
    \r\n \t
  • Affect\/behaviour\/anxiety<\/li>\r\n \t
  • Level of hygiene<\/li>\r\n \t
  • Body position<\/li>\r\n \t
  • Patient mobility<\/li>\r\n \t
  • Speech pattern and articulation<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Alterations may reflect neurologic impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness. Unusual findings should be followed up with a focused neurological system assessment<\/a>.\r\n\r\n[caption id=\"attachment_6427\" align=\"aligncenter\" width=\"300\"]\"DSC_2293\"<\/a> Assess general appearance[\/caption]<\/td>\r\n<\/tr>\r\n
This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full \u00a0body assessment as you work through steps 3-9.<\/em><\/strong>\r\n\r\n2. Skin,\u00a0hair, and nails:\r\n
    \r\n \t
  • Inspect for lesions, bruising, and rashes.<\/li>\r\n \t
  • Palpate\u00a0skin for temperature, moisture, and texture.<\/li>\r\n \t
  • Inspect\u00a0for pressure areas.<\/li>\r\n \t
  • Inspect skin for edema.<\/li>\r\n \t
  • Inspect scalp for lesions and hair and scalp for presence of lice and\/or nits.<\/li>\r\n \t
  • Inspect\u00a0nails for consistency, colour, and capillary refill<\/strong>.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.\r\n\r\nRedness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient's need for position changes.\r\n\r\nUnilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure.\r\n\r\nCheck hair for the presence of lice and\/or nits (eggs), which are oval in shape and adhere to the hair shaft.<\/td>\r\n<\/tr>\r\n
3. Head and neck:\r\n
    \r\n \t
  • Inspect eyes for drainage.<\/li>\r\n \t
  • Inspect eyes for pupillary reaction to light.<\/li>\r\n \t
  • Inspect mouth, tongue, and teeth for moisture, colour, dentures.<\/li>\r\n \t
  • Inspect for facial symmetry.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Check eyes for drainage, pupil size, and reaction to light. Drainage may indicate infection, allergy, or injury.\r\n\r\nSlow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment.\r\n\r\n[caption id=\"attachment_6782\" align=\"aligncenter\" width=\"300\"]\"Check<\/a> Check pupillary reaction to light[\/caption]\r\n\r\nDry mucous membranes indicate decreased hydration.\r\n\r\nFacial asymmetry may indicate neurological impairment or injury.\u00a0Unusual findings should be followed up with a\u00a0focused neurological system assessment<\/a>.<\/td>\r\n<\/tr>\r\n
4. Chest:\r\n
    \r\n \t
  • Inspect:\r\n
      \r\n \t
    • Expansion\/retraction of chest wall\/work of breathing and\/or accessory muscle use<\/li>\r\n \t
    • Jugular distension<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
    • Auscultate:\r\n
        \r\n \t
      • For breath sounds anteriorly and posteriorly<\/li>\r\n \t
      • Apices and bases for any adventitious sounds<\/li>\r\n \t
      • Apical heart rate<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
      • Palpate:\r\n
          \r\n \t
        • For symmetrical lung expansion<\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Chest expansion may be\u00a0asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, or pneumothorax.\r\n\r\nUse of accessory muscles may indicate acute airway obstruction or massive atelectasis.\r\n\r\nJugular distension of more than 3 cm above the sternal angle while the patient is at 45\u00ba may indicate cardiac failure.\r\n\r\nThe presence of crackles or wheezing must be further assessed, documented, and reported. Unusual\u00a0findings should be followed up with a focused respiratory assessment<\/a>.\r\n\r\n[caption id=\"attachment_6777\" align=\"aligncenter\" width=\"300\"]\"Auscultate Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation[\/caption]\r\n\r\n[caption id=\"attachment_6780\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation[\/caption]\r\n\r\n[caption id=\"attachment_6778\" align=\"aligncenter\" width=\"300\"]\"Auscultate<\/a> Auscultate apical pulse at the fifth intercostal space and midclavicular line[\/caption]\r\n\r\nNote the heart rate and rhythm, identify S1 and S2, and follow up on any unusual\u00a0findings with a focused cardiovascular assessment<\/a>.<\/td>\r\n<\/tr>\r\n
5. Abdomen:\r\n
    \r\n \t
  • Inspect:\r\n
      \r\n \t
    • Abdomen for distension, asymmetry<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
    • Auscultate:\r\n
        \r\n \t
      • Bowel sounds (RLQ)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
      • Palpate:\r\n
          \r\n \t
        • Four\u00a0quadrants for pain and bladder\/bowel distension (light palpation only)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
        • Check urine output for\u00a0frequency, colour, odour.<\/li>\r\n \t
        • Determine frequency and type of bowel movements.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.\r\n\r\nHyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum.\r\n\r\nHypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.\r\n\r\nPain and tenderness may indicate underlying inflammatory conditions such as peritonitis.\r\n\r\nUnusual findings in urine output may indicate compromised urinary function. Follow up with a\u00a0focused gastrointestinal and genitourinary assessment<\/a>.\r\n\r\nUnusual findings with bowel movements should be followed up with a\u00a0focused gastrointestinal and genitourinary assessment<\/a>.\r\n\r\n[caption id=\"attachment_6423\" align=\"aligncenter\" width=\"300\"]\"Auscultate Auscultate abdomen[\/caption]\r\n\r\n\"Palpate<\/a><\/td>\r\n<\/tr>\r\n
6. Extremities:\r\n
    \r\n \t
  • Inspect:\r\n
      \r\n \t
    • Arms and legs for pain, deformity, edema, pressure areas, bruises<\/li>\r\n \t
    • Compare bilaterally<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
    • Palpate:\r\n
        \r\n \t
      • Radial pulses<\/li>\r\n \t
      • Pedal pulses: dorsalis pedis and posterior tibial<\/li>\r\n \t
      • CWMS and capillary refill (hands and feet)<\/li>\r\n<\/ul>\r\n<\/li>\r\n \t
      • Assess handgrip strength and equality.<\/li>\r\n \t
      • Assess dorsiflex and plantarflex feet against resistance (note strength and equality).<\/li>\r\n \t
      • Check skin integrity and pressure areas.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Limitation in range of movement may indicate articular disease or injury.\r\n\r\nPalpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications.\r\n\r\nUnequal handgrip and\/or foot strength may indicate underlying conditions, injury, or post-surgical complications.\r\n\r\nCWMS<\/strong>: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion.\r\n\r\nCheck skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.\r\n\r\n[caption id=\"attachment_6414\" align=\"aligncenter\" width=\"300\"]\"A<\/a> Assess dorsiflexion[\/caption]\r\n\r\n[caption id=\"attachment_6413\" align=\"aligncenter\" width=\"300\"]\"A<\/a> Assess plantarflexion[\/caption]\r\n\r\n[caption id=\"attachment_6415\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess CWMS - colour, warmth, movement, and sensation[\/caption]\r\n\r\n[caption id=\"attachment_6426\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess bilateral hand strength[\/caption]\r\n\r\nPalpate and inspect capillary refill\u00a0and report if more than 3 seconds.\r\n\r\n[caption id=\"attachment_6442\" align=\"aligncenter\" width=\"300\"]\"Assess<\/a> Assess pedal pulses[\/caption]\r\n\r\n[caption id=\"attachment_6441\" align=\"aligncenter\" width=\"300\"]\"Check<\/a> Check capillary refill[\/caption]\r\n\r\nTo\u00a0check capillary\u00a0refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction.\u00a0Unusual\u00a0findings should be followed up with a\u00a0focused cardiovascular assessment.<\/a>\r\n\r\nClubbing<\/strong> of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis.<\/td>\r\n<\/tr>\r\n
7. Back area (turn patient to side or ask to sit up or lean forward):\r\n
    \r\n \t
  • Inspect back and spine.<\/li>\r\n \t
  • Inspect coccyx\/buttocks.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Check for curvature or abnormalities in the spine.\r\n\r\nCheck skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.<\/td>\r\n<\/tr>\r\n
8. Tubes, drains, dressings, and IVs:\r\n
    \r\n \t
  • Inspect for drainage, position,\u00a0and function.<\/li>\r\n \t
  • Assess wounds for unusual drainage.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Note amount, colour, and consistency of drainage (e.g., Foley catheter), or if infusing as prescribed (e.g., intravenous).\r\n\r\n[caption id=\"attachment_6386\" align=\"aligncenter\" width=\"199\"]\"Urinary<\/a> Urinary catheter bag[\/caption]\r\n\r\nAssess wounds for large amounts of drainage or for purulent drainage, and provide wound care<\/a> as indicated.<\/td>\r\n<\/tr>\r\n
9. Mobility:\u00a0<\/strong>\r\n
    \r\n \t
  • Check if full or partial weight-bearing.<\/li>\r\n \t
  • Determine gait\/balance.<\/li>\r\n \t
  • Determine need for and use of assistive devices.<\/li>\r\n<\/ul>\r\n<\/td>\r\n
Assess patient's risk for falls. Document and follow up any indication of falls risk. Note use of mobility aids and ensure they are available to the patient on\u00a0ambulation.\r\n\r\n[caption id=\"attachment_6132\" align=\"aligncenter\" width=\"174\"]\"Patient<\/a> Patient position prior to standing[\/caption]<\/td>\r\n<\/tr>\r\n
10. Report and document assessment findings and related health problems according to agency policy.<\/td>\r\nAccurate and timely documentation and reporting promote patient safety.<\/td>\r\n<\/tr>\r\n
Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n
\r\n

Critical Thinking Exercises<\/p>\r\n\r\n<\/header>\r\n

\r\n
    \r\n \t
  1. You are assessing a patient at the beginning of your shift. Which assessment would be the most appropriate?<\/li>\r\n \t
  2. You come back from a break to find your patient complaining that she feels short of breath.\u00a0Which assessment would be the most appropriate?<\/li>\r\n<\/ol>\r\n<\/div>\r\n<\/div>","rendered":"

    A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition. Any unusual findings should be followed up with a focused assessment<\/a> specific to the affected body system.<\/p>\n

    A physical examination involves collecting objective data\u00a0using the techniques of inspection, palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 outlines the steps to take.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
    <\/a>Checklist 17: Head-to-Toe Assessment<\/caption>\n
    \n
    Disclaimer:\u00a0Always review and follow your hospital policy regarding this specific skill.<\/h5>\n<\/td>\n<\/tr>\n
    \n
    Safety considerations:<\/h5>\n
    \n

    Steps<\/h4>\n<\/td>\n

    		\n

    Additional Information<\/h4>\n<\/td>\n<\/tr>\n

    1. General appearance:<\/p>\n
      \n
    • Affect\/behaviour\/anxiety<\/li>\n
    • Level of hygiene<\/li>\n
    • Body position<\/li>\n
    • Patient mobility<\/li>\n
    • Speech pattern and articulation<\/li>\n<\/ul>\n<\/td>\n
    		Alterations may reflect neurologic impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness. Unusual findings should be followed up with a focused neurological system assessment<\/a>.<\/p>\n
    \"DSC_2293\"<\/a>
    Assess general appearance<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full \u00a0body assessment as you work through steps 3-9.<\/em><\/strong><\/p>\n

    2. Skin,\u00a0hair, and nails:<\/p>\n

      \n
    • Inspect for lesions, bruising, and rashes.<\/li>\n
    • Palpate\u00a0skin for temperature, moisture, and texture.<\/li>\n
    • Inspect\u00a0for pressure areas.<\/li>\n
    • Inspect skin for edema.<\/li>\n
    • Inspect scalp for lesions and hair and scalp for presence of lice and\/or nits.<\/li>\n
    • Inspect\u00a0nails for consistency, colour, and capillary refill<\/strong>.<\/li>\n<\/ul>\n<\/td>\n
    		Check for and follow up on the presence of lesions, bruising, and rashes.Variations in skin temperature, texture, and perspiration or dehydration may indicate underlying conditions.<\/p>\n

    Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes.<\/p>\n

    Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure.<\/p>\n

    Check hair for the presence of lice and\/or nits (eggs), which are oval in shape and adhere to the hair shaft.<\/td>\n<\/tr>\n

    3. Head and neck:<\/p>\n
      \n
    • Inspect eyes for drainage.<\/li>\n
    • Inspect eyes for pupillary reaction to light.<\/li>\n
    • Inspect mouth, tongue, and teeth for moisture, colour, dentures.<\/li>\n
    • Inspect for facial symmetry.<\/li>\n<\/ul>\n<\/td>\n
    		Check eyes for drainage, pupil size, and reaction to light. Drainage may indicate infection, allergy, or injury.<\/p>\n

    Slow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment.<\/p>\n

    \"Check<\/a>
    Check pupillary reaction to light<\/figcaption><\/figure>\n

    Dry mucous membranes indicate decreased hydration.<\/p>\n

    Facial asymmetry may indicate neurological impairment or injury.\u00a0Unusual findings should be followed up with a\u00a0focused neurological system assessment<\/a>.<\/td>\n<\/tr>\n

    4. Chest:<\/p>\n
      \n
    • Inspect:\n
        \n
      • Expansion\/retraction of chest wall\/work of breathing and\/or accessory muscle use<\/li>\n
      • Jugular distension<\/li>\n<\/ul>\n<\/li>\n
      • Auscultate:\n
          \n
        • For breath sounds anteriorly and posteriorly<\/li>\n
        • Apices and bases for any adventitious sounds<\/li>\n
        • Apical heart rate<\/li>\n<\/ul>\n<\/li>\n
        • Palpate:\n
            \n
          • For symmetrical lung expansion<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/td>\n
    		Chest expansion may be\u00a0asymmetrical with conditions such as atelectasis, pneumonia, fractured ribs, or pneumothorax.<\/p>\n

    Use of accessory muscles may indicate acute airway obstruction or massive atelectasis.<\/p>\n

    Jugular distension of more than 3 cm above the sternal angle while the patient is at 45\u00ba may indicate cardiac failure.<\/p>\n

    The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual\u00a0findings should be followed up with a focused respiratory assessment<\/a>.<\/p>\n

    \"Auscultate
    Auscultate anterior chest; blue dots indicate stethoscope placement for auscultation<\/figcaption><\/figure>\n
    \"Auscultate<\/a>
    Auscultate posterior chest; blue dots indicate stethoscope placement for auscultation<\/figcaption><\/figure>\n
    \"Auscultate<\/a>
    Auscultate apical pulse at the fifth intercostal space and midclavicular line<\/figcaption><\/figure>\n

    Note the heart rate and rhythm, identify S1 and S2, and follow up on any unusual\u00a0findings with a focused cardiovascular assessment<\/a>.<\/td>\n<\/tr>\n

    5. Abdomen:<\/p>\n
      \n
    • Inspect:\n
        \n
      • Abdomen for distension, asymmetry<\/li>\n<\/ul>\n<\/li>\n
      • Auscultate:\n
          \n
        • Bowel sounds (RLQ)<\/li>\n<\/ul>\n<\/li>\n
        • Palpate:\n
            \n
          • Four\u00a0quadrants for pain and bladder\/bowel distension (light palpation only)<\/li>\n<\/ul>\n<\/li>\n
          • Check urine output for\u00a0frequency, colour, odour.<\/li>\n
          • Determine frequency and type of bowel movements.<\/li>\n<\/ul>\n<\/td>\n
    		Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.<\/p>\n

    Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum.<\/p>\n

    Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.<\/p>\n

    Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis.<\/p>\n

    Unusual findings in urine output may indicate compromised urinary function. Follow up with a\u00a0focused gastrointestinal and genitourinary assessment<\/a>.<\/p>\n

    Unusual findings with bowel movements should be followed up with a\u00a0focused gastrointestinal and genitourinary assessment<\/a>.<\/p>\n

    \"Auscultate
    Auscultate abdomen<\/figcaption><\/figure>\n

    \"Palpate<\/a><\/td>\n<\/tr>\n

    6. Extremities:<\/p>\n
      \n
    • Inspect:\n
        \n
      • Arms and legs for pain, deformity, edema, pressure areas, bruises<\/li>\n
      • Compare bilaterally<\/li>\n<\/ul>\n<\/li>\n
      • Palpate:\n
          \n
        • Radial pulses<\/li>\n
        • Pedal pulses: dorsalis pedis and posterior tibial<\/li>\n
        • CWMS and capillary refill (hands and feet)<\/li>\n<\/ul>\n<\/li>\n
        • Assess handgrip strength and equality.<\/li>\n
        • Assess dorsiflex and plantarflex feet against resistance (note strength and equality).<\/li>\n
        • Check skin integrity and pressure areas.<\/li>\n<\/ul>\n<\/td>\n
    		Limitation in range of movement may indicate articular disease or injury.<\/p>\n

    Palpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications.<\/p>\n

    Unequal handgrip and\/or foot strength may indicate underlying conditions, injury, or post-surgical complications.<\/p>\n

    CWMS<\/strong>: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion.<\/p>\n

    Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.<\/p>\n

    \"A<\/a>
    Assess dorsiflexion<\/figcaption><\/figure>\n
    \"A<\/a>
    Assess plantarflexion<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess CWMS – colour, warmth, movement, and sensation<\/figcaption><\/figure>\n
    \"Assess<\/a>
    Assess bilateral hand strength<\/figcaption><\/figure>\n

    Palpate and inspect capillary refill\u00a0and report if more than 3 seconds.<\/p>\n

    \"Assess<\/a>
    Assess pedal pulses<\/figcaption><\/figure>\n
    \"Check<\/a>
    Check capillary refill<\/figcaption><\/figure>\n

    To\u00a0check capillary\u00a0refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction.\u00a0Unusual\u00a0findings should be followed up with a\u00a0focused cardiovascular assessment.<\/a><\/p>\n

    Clubbing<\/strong> of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis.<\/td>\n<\/tr>\n

    7. Back area (turn patient to side or ask to sit up or lean forward):<\/p>\n
      \n
    • Inspect back and spine.<\/li>\n
    • Inspect coccyx\/buttocks.<\/li>\n<\/ul>\n<\/td>\n
    		Check for curvature or abnormalities in the spine.<\/p>\n

    Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.<\/td>\n<\/tr>\n

    8. Tubes, drains, dressings, and IVs:<\/p>\n
      \n
    • Inspect for drainage, position,\u00a0and function.<\/li>\n
    • Assess wounds for unusual drainage.<\/li>\n<\/ul>\n<\/td>\n
    		Note amount, colour, and consistency of drainage (e.g., Foley catheter), or if infusing as prescribed (e.g., intravenous).<\/p>\n
    \"Urinary<\/a>
    Urinary catheter bag<\/figcaption><\/figure>\n

    Assess wounds for large amounts of drainage or for purulent drainage, and provide wound care<\/a> as indicated.<\/td>\n<\/tr>\n

    9. Mobility:\u00a0<\/strong><\/p>\n
      \n
    • Check if full or partial weight-bearing.<\/li>\n
    • Determine gait\/balance.<\/li>\n
    • Determine need for and use of assistive devices.<\/li>\n<\/ul>\n<\/td>\n
    		Assess patient’s risk for falls. Document and follow up any indication of falls risk. Note use of mobility aids and ensure they are available to the patient on\u00a0ambulation.<\/p>\n
    \"Patient<\/a>
    Patient position prior to standing<\/figcaption><\/figure>\n<\/td>\n<\/tr>\n
    10. Report and document assessment findings and related health problems according to agency policy.<\/td>\nAccurate and timely documentation and reporting promote patient safety.<\/td>\n<\/tr>\n
    Data source:\u00a0Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n
    \n
    \n

    Critical Thinking Exercises<\/p>\n<\/header>\n

    \n
      \n
    1. You are assessing a patient at the beginning of your shift. Which assessment would be the most appropriate?<\/li>\n
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