Bedside Assessment: Head to Toe
Bedside Assessment
Introduction: Foam in. Explain procedure. Verify name, DOB, Allergies.
Assess LOC: Do you know where you are? and what day it is?
VITALS
* Temp: Anything to eat/drink in last 20 minutes? Temp is ___ “is within normal range of 96.4 - 99.1” * HR (50-90 bpm) and Respirations (10-20/min) for 30 seconds each * BP 120/80
* Pulse Ox 97-100 * Pupils: PERRLA - 3mm at rest and constrict to 2 mm with light * Pain: Rating from 1-10. Any abdominal pain?
Any problems urinating/bowel movements? When was your last bowel movement?
2nd ICS, Rt sternal border: Aortic
2nd ICS, Left sternal border: Pulmonic
3rd ICS, Left sternal border: Erb's Point
4th ICS, Left sternal border: Tricuspid
5th ICS, Mid-Clavicuar: Mitral
2nd ICS, Rt sternal border: Aortic
2nd ICS, Left sternal border: Pulmonic
3rd ICS, Left sternal border: Erb's Point
4th ICS, Left sternal border: Tricuspid
5th ICS, Mid-Clavicuar: Mitral
Heart Sounds:
Lung Sounds: Start 3-4 cm above clavicle. Listen from full inspiration and expiration. Verbalize you would listen to 10-12 places comparing bilaterally. Also, listen to lower lobes laterally: 2 spots on rt, 1 on left
Bowel Sounds: Ask when the last meal was. Listen to RLQ, RUQ, LUQ, LLQ. “I can hear gurgling”.
Assess upper half of body: * Carotid, brachial, radial, and ulnar pulses - All pulses 2+ Normal * Assess skin color and temp - "Pink and warm to touch" * Capillary refill on hands - Less than 2 seconds * Assess for clubbing * Squeeze hands - Strength equal bilaterally
Assess lower half of body: * Femoral, Poplital, post Tibial, and pedal pulses - All 2+ Normal * Assess skin color and temp - "Pink and warm to touch" * Also assess for edema (pretibial edema) and skin breakdown (heels) * Capillary refill on toes - Less than 2 seconds * Assess for clubbing * Push and pull against hands - Strength equal bilaterally
"Is there anything else I can get
Introduction: Foam in. Explain procedure. Verify name, DOB, Allergies.
Assess LOC: Do you know where you are? and what day it is?
VITALS
* Temp: Anything to eat/drink in last 20 minutes? Temp is ___ “is within normal range of 96.4 - 99.1” * HR (50-90 bpm) and Respirations (10-20/min) for 30 seconds each * BP 120/80
* Pulse Ox 97-100 * Pupils: PERRLA - 3mm at rest and constrict to 2 mm with light * Pain: Rating from 1-10. Any abdominal pain?
Any problems urinating/bowel movements? When was your last bowel movement?
2nd ICS, Rt sternal border: Aortic
2nd ICS, Left sternal border: Pulmonic
3rd ICS, Left sternal border: Erb's Point
4th ICS, Left sternal border: Tricuspid
5th ICS, Mid-Clavicuar: Mitral
2nd ICS, Rt sternal border: Aortic
2nd ICS, Left sternal border: Pulmonic
3rd ICS, Left sternal border: Erb's Point
4th ICS, Left sternal border: Tricuspid
5th ICS, Mid-Clavicuar: Mitral
Heart Sounds:
Lung Sounds: Start 3-4 cm above clavicle. Listen from full inspiration and expiration. Verbalize you would listen to 10-12 places comparing bilaterally. Also, listen to lower lobes laterally: 2 spots on rt, 1 on left
Bowel Sounds: Ask when the last meal was. Listen to RLQ, RUQ, LUQ, LLQ. “I can hear gurgling”.
Assess upper half of body: * Carotid, brachial, radial, and ulnar pulses - All pulses 2+ Normal * Assess skin color and temp - "Pink and warm to touch" * Capillary refill on hands - Less than 2 seconds * Assess for clubbing * Squeeze hands - Strength equal bilaterally
Assess lower half of body: * Femoral, Poplital, post Tibial, and pedal pulses - All 2+ Normal * Assess skin color and temp - "Pink and warm to touch" * Also assess for edema (pretibial edema) and skin breakdown (heels) * Capillary refill on toes - Less than 2 seconds * Assess for clubbing * Push and pull against hands - Strength equal bilaterally
"Is there anything else I can get