Pedal pulses/Head to toe assesments

[Florence NightinFAIL, BSN, RN]

Do you check pedal pulses on all your patient's regardless of their diagnosis or history? Example: for a pt that came in with diarrhea and is otherwise independent with history/risk factor for dvt/PE/PVD.

I was discussing head to toe assessment with some nurses and some of them said that they sometimes don't do a full head to toe assessment at all. They just do a focused assessment if a pt is stable. Ex: if a pt came in with cellulitis of the leg, they wouldn't listen to their chest or abdomen, ETC. I was really surprised.

[BostonFNP, APRN]

IMHO.

Even focused exams should include a comment on: orientation, skin, pupils, lungs, heart rate & rhythm, pedal pulses and edema, bowel sounds.

If you don't do a full head-to-toe, then I would at bare minimum comment on those areas plus your focus area.

[RunBabyRN]

I always check. Same for listening to the lungs and heart tones. Even if someone has been stable, that doesn't mean their condition can't change at any time, and I wouldn't want to be the nurse that missed something like that. I do a skin check, assess for edema, and do a quick me pro and strength check when I check pedal pulses. Takes me 30 seconds.

[vintage_RN, BSN, RN]

I always do a full head to toe. Takes about 3 minutes (I'm a new nurse)...but you never know what could go wrong. Especially with things like checking chest/lungs and pulses (I was on a surgical floor). Best to be safe, IMO.

[artisticmind]

I'm a relatively new nurse on a Progressive Care Unit (7 months since I started!) but I always check pedal pulses. My 1st assessment I take socks off or push TEDS up and check pulses and cap refills, 2nd and 3rd (if designated as a PCU patient rather than Tele) I will check pulses through teds/socks if I can feel them, if not I'll remove socks again. I always check, lungs, heart, and bowels as well. I've had patients go from clear/dim to coorifice/crackles pretty quick just between assessments.

[applewhitern, BSN, RN]

I do, but I am an ICU nurse. How do you know if something has changed, if you don't do a thorough assessment?

[NurseKatie08, MSN]

I check everything, always with a full, thorough head to toe assessment. I think it's scary that people don't.

[RNperdiem, RN]

I always do check all the pulses. Most of the patients here are trauma patients, and you do want to be sure you can find all the pulses.

Now if my patient is alert and talking to me, I skip the gag/cough/corneals unless there is a neuro diagnosis.

[AJJKRN]

I do my same head to toe assessment, every time, on every patient regardless of their chief complaint/diagnosis.

How else would one discern their baseline from any changes?

Besides that, most of my patients are a hot mess with a plethora of problems no matter what floor I float to at my facility!

[ArtClassRN, ADN, RN]

Do you check pedal pulses on all your patient's regardless of their diagnosis or history? Example: for a pt that came in with diarrhea and is otherwise independent with history/risk factor for dvt/PE/PVD.

I was discussing head to toe assessment with some nurses and some of them said that they sometimes don't do a full head to toe assessment at all. They just do a focused assessment if a pt is stable. Ex: if a pt came in with cellulitis of the leg, they wouldn't listen to their chest or abdomen, ETC. I was really surprised.

They call it head to toe for a reason.

[wanderlust99]

Agree with above posts. It's bare minimum. You know you've had a patient with edema that no one has charted on for days. Is it new? Or did no one check it for a couple shifts? Or that distended abdomen that no one mentioned in report and no one charted on. Has it always been that way?

Agree with what above poster said, basic assessment includes orientation (just talking to the pt gives you this usually), lungs, heart, VS, edema, pulses, palpate the abd and take a listen for BS and check the skin.