When should an assessment be done
-Beginning of the each shift
-Weekly or monthly in long term care
-Whenever a change occurs
-Whenever the nurse thinks necessary
What is a head to toe assessment?
A Physical assessment of each body system that offers objective info about the patient.
Assessment of Skin
-Ask pt. if they have noticed any changes in skin
-A change in a bump or nodule
-A change in sensation (tenderness or pain)
-Is the pt. pink, pale, cyanotic, or ruddy
Assessment of Eyes
-Are pupils clear?
-Check pupils with pen light and lights turned down
-Check size prior to checking reflexes with light
-Size 2-9 mm, normal 3-5 mm