Head-To-Toe Assessment
This tool is used to assess a patient’s level of consciousness, scoring eye, verbal, and motor responses
What is Glasgow Coma Scale?
A heart rate over 100 bpm is called this.
What is tachycardia?
Drooping of one side of the face may indicate this.
What is a stroke?
This sound indicates fluid in the alveoli and is often heard in heart failure
What are crackles?
A patient is found with a RR of 8 after opioid administration. Your first action is:
What is assess airway and prepare to administer naloxone?
Capillary refill greater than this many seconds may indicate poor perfusion.
What is 3 seconds?
This blood pressure reading is considered a hypertensive crisis.
What is >180/120 mmHg?
Confusion, irritability, and drowsiness can be early signs of this complication.
What is increased intracranial pressure (ICP)?
An SpO₂ below this value typically indicates hypoxemia
What is 90%?
The post-op patient’s wound is dehiscing. What’s your priority action?
What is cover with sterile saline-soaked dressing and call provider?
Auscultating bowel sounds in this pattern is considered best practice
What is RLQ, RUQ, LUQ, LLQ?
A temperature of 100.4 or greater may indicate this.
What is a fever?
Sudden inability to speak or understand language is known as this.
What is aphasia?
This high-pitched inspiratory sound suggests upper airway obstruction
What is stridor?
A confused patient keeps trying to pull out IV lines. What’s the safest intervention?
What is use a sitter or implement least restrictive safety measures?
This pupillary reaction finding may indicate increased ICP
What is unequal or sluggish?
A MAP below this value indicates inadequate organ perfusion.
What is 65 mmHg?
This posturing indicates severe brain damage and includes extension and internal rotation of the arms.
What is decerebrate posturing?
Sudden dyspnea and chest pain in a post-op patient may indicate this
What is a pulmonary embolism?
A patient’s potassium returns at 6.8 mEq/L. What should you do immediately?
What is place on a cardiac monitor and contact provider?
This skin assessment finding over the sacrum may be an early sign of pressure injury
What is non-blanchable erythema?
This breathing pattern characterized by irregular rate and depth may signal impending death.
What is Cheyne-Stokes respirations?
A positive Babinski reflex in an adult may indicate this type of issue.
What is an upper motor neuron lesion?
In asthma exacerbation, this sound may suddenly disappear indicating worsening condition.
What is wheezing or silent chest?
A patient reports chest pain unrelieved by rest. What’s your immediate action?
What is administer nitro (per protocol) and notify provider?