LONG Head to Toe
Safety
- bed low and locked
- position
- call bell and belongings w/in reach
Vitals
- q4 (0800, 1200)
Neuro/head
- orientation (person, place, time, event) - PERRLA
- symmetry, speech, smile
- dentures, gums, mucosa, tongue
- lymph, carotid, JVD
Skin/upper body
- color, temp, turgor
- cap refill, vascularity (brachial/radial)
- grips
- lesions,bruising, ulcers, pressure sores,
- elbows (lift arms), sacrum, under knees, heels
- edema
- IVs (puncture site, right solution)
Chest
- symmetry, rises and falls, accessory muscle used for breathing
- heart rate (aortic, pulmonic, erbs, tricuspid, apical)
Lungs
- lung sounds (reg or adventitious), compare bilaterally
- RR
- cough, dyspnea
- nasal cannula/O2 rt
Abdomen
- swelling, girth, pulsations, tenderness - RLQ, RUQ, LUQ, LLQ
** posterior lung sounds, sacral edema
Lower extremities
- compare bilat, edema
- color, temp
- cap refill, pulses (dorsalis pedis, posterior tibial)
- lesions, bruising, ulcers, pressure sores (under knees, heels)
- Holman’s (flex foot, calf pain?)
Urinary
- output
- foley care
Musculoskeletal
- mvmt
- rom
- ADLs
- CMS (circulation, motor, sensory)
Ortho Head to Toe (due post breakfast before 9AM)
- Safety
- Vitals q 4 (8, 12)
- Orientation (person, place, time, event)
- Heart
- Lungs
- Bowel (RLQ, RUQ, LUQ, LLQ)
- Catheter
- Radial pulse, cap refill
- Legs (dressing, compare affected w/ non effected leg)
- Neurovascular
Circulation, Motor, Sensation wiggle toes, gas, noes, close eyes
- Skin - Braden
- IV assess (site, correct solution) - O2 flow (correct L/min)
- Foley (straight drain, q shift)
Misc.
- hourly rounding (4P’s: potty, possession, position, pain)
- 5 P’s: pain, pulse, pallor, paraesthesia & paralysis
- know what’s going in and out of pt
- q4 neuro
- d/c teaching
- linen change post PT