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Checklist ng Head-to-Toe Assessment

3 min na pagbabasa

Checklist ng Head-to-Toe Assessment

Mahahalagang Punto

  • Gumamit ng pare-parehong sequence upang mabawasan ang missed findings at mapabuti ang linaw ng handoff.
  • Magsimula sa safety, identity, at primary survey bago ang detalyadong system assessment.
  • Ang bedside head-to-toe assessment ay nagtatakda ng praktikal na inpatient baseline, habang ang focused assessment ay tumitiyak sa chief complaint.
  • Isama ang subjective at objective data sa bawat system check.
  • I-escalate agad ang unanticipated findings ayon sa agency protocol.

Kagamitan

  • Stethoscope at penlight
  • Relo na may second hand
  • Gloves, hand sanitizer, at indicated PPE
  • Wound measurement tool (kung may sugat)

Mga Hakbang sa Pamamaraan

  1. Ihanda ang kinakailangang supplies, gawin ang kalinisan ng kamay, at disimpektahin ang stethoscope bago makipag-ugnayan sa pasyente.
  2. Pumasok gamit ang safety protocol: kumatok, tasahin ang transmission-based precautions, ipakilala ang role/purpose/time estimate, protektahan ang privacy/dignity, at kumpirmahin ang dalawang identifiers.
  3. Isagawa ang primary survey para sa agarang stability (airway, breathing, circulation, mental status) at i-activate ang emergency support kung unstable.
  4. Kumpletuhin ang general survey (appearance, behavior, mood, mobility/coordination, communication, nutrition/fluid cues), tugunan ang agarang pangangailangan (halimbawa toileting, salamin, hearing aids), at linawin ang chief concern gamit ang PQRSTU-based prompts.
  5. Kunin/suriin ang vital signs at pain/discomfort status; i-escalate agad ang out-of-range o clinically concerning findings.
  6. Isagawa ang neuromuscular assessment: sintomas (headache/dizziness/weakness/numbness/tremor/swallowing/balance/falls), orientation, PERRLA, bilateral strength/sensation, at fall-risk screening.
  7. Isagawa ang HEENT assessment: head inspection/palpation; eye checks kabilang ang PERRLA at basic visual concerns; ear at hearing-aid status; nose concerns; at mouth/throat findings.
  8. Isagawa ang cardiovascular assessment: chest-symptom history, skin color/perfusion, JVD context, edema/DVT cues, bilateral pulse comparison, capillary refill, heart-sound auscultation, at apical pulse sa loob ng isang minuto.
  9. Isagawa ang respiratory assessment: dyspnea/cough/smoking history, breathing pattern/effort, chest movement, tracheal alignment, bilateral lung auscultation, oxygen-device details, at tracheostomy/site o sputum characteristics kung mayroon.
  10. Isagawa ang abdominal assessment: GI symptom review, contour/distension inspection, bowel sounds, light palpation/percussion context, appetite at nutrition cues, at stool pattern concerns.
  11. Isagawa ang peripheral vascular assessment: inspeksyunin ang perfusion at color, palpahin ang pulses at edema, at tasahin ang pain, paresthesia, pallor, poikilothermia, o paralysis cues na nangangailangan ng urgent escalation.
  12. Isagawa ang GU/activity assessment: voiding pattern, catheter/device status, reproductive symptom concerns kung naaangkop, mobility/activity tolerance, at ADL safety implications.
  13. Isagawa ang integumentary assessment: global skin findings, pressure-point breakdown screening, wound/pressure-injury review, IV-site condition, edema grading, at palpation para sa temperature/moisture/texture changes.
  14. I-reposition para sa ginhawa, kumpletuhin ang room safety checks (call light, bed low/locked, rails/table, fall-hazard scan), alisin ang PPE kung naaangkop, ulitin ang hand hygiene/stethoscope cleaning, idokumento ang findings, at iulat ang unanticipated findings ayon sa policy.

Prayoridad sa Escalation

Huwag antalahin ang escalation kapag lumitaw ang primary-survey instability o mga bagong high-risk findings habang isinasagawa ang checklist.

Kaugnay

Graph View