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#Head to toe assessment checklist skin

Perform a general survey while completing the head-to-toe assessment.Mental Status: Is the patient responsive and alert?.

#Head to toe assessment checklist skin

Circulation: Are there any abnormal findings in the overall color and moisture of the patient’s skin (cyanosis, diaphoresis).

Breathing: Is the patient breathing normally?.

Airway: Is the airway open? Is suctioning needed?.

Perform a primary survey to ensure medical stability.

Identify the patient with two appropriate identifiers.

Use appropriate listening and questioning skills.

During the assessment, listen and attend to patient cues.

Explain the planned task and estimate the duration of time to complete it.Ask if the patient is comfortable if others are present in the room during the assessment. Ask the patient’s preferred way of being addressed. Greet the patient and others in the room.Greet the patient, introduce oneself, explain the task, and provide privacy.Check the room for transmission-based precautions. Perform hand hygiene before providing care and clean stethoscope.Gather supplies: stethoscope, penlight, watch with second hand, gloves, hand sanitizer, and wound measurement tool.Unanticipated findings should be reported per agency protocol with emergency assistance obtained as indicated. Focused assessments should be performed for abnormal findings and according to specialty unit guidelines. Assessment techniques should be modified according to life span considerations. Students should use a systematic approach and include these components in their assessment and documentation. This checklist is intended as a guide for a routine, general, daily assessment performed by an entry-level nurse during inpatient care. Appendix C – Head-to-Toe Assessment Checklist Head-to-Toe Assessment Checklist