Having a healthy or reddish color.
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.
Inspect the eyes for:
Size, color, shape, and symmetry
How deep do you palpate?
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
Assessing the Mouth
-Any loose teeth
-Edentulous (no teeth)
-Inspect the oral mucosa, look at gums, teeth, tongue, cheek
-look for any lesions
-Is it moist or Dry
-May need to remove Dentures to look
-Want to see Uvula and soft palate rise symmetrically when pt. says 'Ahhh'