Complete a head-to-toe physical assessment
Reinforce the nursing head-to-toe order from clinical-skills training. Documentation is not closed until airway/vitals, then systems from head to toe, are finished.
- Identify the patient.
- Obtain vital signs.
- Inspect and assess the head, neck, and airway.
- Auscultate heart and lungs before the abdomen if the protocol requires it.
- Examine the abdomen.
- Examine extremities and skin.
- Complete a focused neuro check.
- Document abnormal findings before leaving the bedside.
- Do not skip to a favorite system first.