Head to toe assessment in 5 minutes? - page 2

We just started on HTTA in lab & our instructor said she feels by 4th term we'll be able to do them in 5 minutes. Considering they expect us while students to take the pulse for a full minute, count... Read More

  1. by   Curious1alwys
    Well, I am in my last semester and I still forget stuff and have to go back in!! I must be getting better though because I do the whole "walk in and start scanning" bit, lol.

    THANK YOU SO MUCH Daytonite for that sheet.:flowersfo We CAN take paperwork in and this will be invaluable to me, to really make sure I am checking everything!! I saved it!

    My instructor thinks assessment shouldn't take longer than 3 minutes either cuz she says that is all the time you have in real life. You should focus primarily on the systems affected (ie, why the pt is in the hospital).
  2. by   kimber1985
    There are alot of things, as a student, that I don't like about physical assessment.
    1. why am I listening to the heart in 5 places? Am I not a cardiologist
    2. why am I listening to the lungs up top first when adventious sounds are usually at the bottom?
    3. If the guys been in the hospital for 1 day, why am I testing for Homan's?
    4. Unless he has a GI problem, bowel sounds are heard and move on.
    5. If pulses are felt strong in extremites why go further up the body?

    I do focus on the diagnosis and try to hear what is not right, and I have caught lung sound and heart sounds not regular that were not charted. I can do it in 5 minutes, but I prioritize the assessment. But I always have to go back for capillary refill. I always forget that, unless my patient has an O2 issue.

    I find that I do it quick, but I am trying to find something wrong at the same time. I am learning, so I focus on what I can hear or see that is going to be good for my patient or a learning experience for me.
  3. by   Mags4711
    Kimber, you ask a lot of really good questions. In practice you will realize the answers to lots of these.
    I have caught murmurs that others haven't heard because I did take the time and listen to the heart in five places. Things can change frequently, especially in sicker patients and there isn't a cardiologist listening to the folks three or five or ten times a day, but there is a nurse doing it.

    As for lung sounds, here's a snippet I found on an assessment website, hope it kind of explains it:

    Auscultation: Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.
    The upper aspect of the posterior fields (i.e. towards the top of the patient's back) are examined first. Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat. This again makes use of one lung as a source of comparison for the other. The entire posterior chest can be covered by listening in roughly 4 places on each side. Of course, if you hear something abnormal, you'll need to listen in more places.
    Lung Auscultation
    1. The lingula and right middle lobes can be examined while you are still standing behind the patient.
    2. Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright. Asking female patients to lie down will allow their breasts to fall away laterally, which may make this part of the examination easier.
    You also start at the top when percussing because "the goal is to recognize that at some point as you move down towards the base of the lungs, the quality of the sound changes. This normally occurs when you leave the thorax. It is not particularly important to identify the exact location of the diaphragm, though if you are able to note a difference in level between maximum inspiration and expiration, all the better. Ultimately, you will develop a sense of where the normal lung should end by simply looking at the chest. The exact vertebral level at which this occurs is not really relevant. "

    Testing for Homan's: The guy may only have been in the hospital for a day, but what was he doing before that? Was he an active person or a couch potato? Did he have surgery the day he was admitted? I have seen people develop clots in a day, or less...

    If bowel sounds are present in all four quadrants and the patient can tell you she's stooling or passing flatus, I agree, no need to listen for a full minute unless there is some reason to (suspected or confirmed GI issue).

    I also agree about the pulse thing as long as you check DP, PT and radial pulses...unless the person has had surgery or a broken bone on that extremity, then I'd check further pulses because that gives you the opportunity to assess the character of the pulse, and appearance of the extremity.

    I can do a head to toe in about 90 seconds. But I do it the same way everytime. That way I do not forget anything along the journey. It truly does start when you walk in the door and greet the person, when turning on the light to begin, you can assess PERRL. Glancing around you can see the foley bag, IV bag, etc.. Shaking hands, you assess extremities and color, etc...
  4. by   kimber1985
    Thank you for the excellent advice.
  5. by   cardiacRN2006
    Quote from kimber1985
    There are alot of things, as a student, that I don't like about physical assessment.
    1. why am I listening to the heart in 5 places? Am I not a cardiologist
    2. why am I listening to the lungs up top first when adventious sounds are usually at the bottom?
    3. If the guys been in the hospital for 1 day, why am I testing for Homan's?
    4. Unless he has a GI problem, bowel sounds are heard and move on.
    5. If pulses are felt strong in extremites why go further up the body?

    .
    1. Because murmurs (especially new onset ones), are an important assessment finding. If you only listen in one place, you may miss them. Then someone else will chart that they heard it and you will look like you didn't do a complete assessment.

    2. Because it's easier for the pt do assess lung sounds from top to bottom. While they are lying flat, assess the tops, and then move down, and then have the pt roll over and do the same. However, not all adventitious sounds are just in the bases. Most wheezes and coarse rhonchi are heard up top.

    3. You'd be suprised how quickly a clot can form. In addition, your pts need a complete assessment.

    4. You'd be suprised how a pt with a quite bowel can be missed assessment after assessment. I had a pt with dead bowel, and it had been charted that he had +bs. The dr actually came in the room and said, "nope, I hear BS." I told him that when you push your steth so far down in his belly, that of course you will hear something. We both listened for a few minuntes, heard nothing after that, got a CT, and the pt had over 10 feet of dead bowel, He was rushed to surgery.

    5. Again, you'd be suprised how quickly a clot can form-even in only one extremity. The last thing you want to see is that the pt had a history of no pulses in one location (like the radial artery if it has been used for CABG) and you have been charting that they were present.


    I guess the point is, your pts deserve a complete initial assessment, and you don't want to look incompetent by charting something that isn't true. The drs will lose faith in you.
  6. by   Chaya
    Initially I introduce myself, check name band,and just ask how they're doing and if there's any pain or discomfort. (You are assessing general wellness, orientation, comfort level). I rapidly eyeball equipment: Tele,Foley output, IV, PEG feed, wound vac. CPM, etc. I check if dressings are clean and intact. With steth out; vital signs if not recently taken, lungs, heart, bowels. Lungs sounds one breath in and out each L upper, R upper, L lower and R lower. Realistically we only listen to AP and bowel for 15 sec each; I inquire about last BM and appetite at this point and do a quick general palpation of the abdomen (I'm not trying to feel their internal organs unless I know there's some pathology, just see if they jump) Then I palpate pulses and assess edema if any. I try to do a directed assessment acc to their diagnoses, ie more thorough respiratory if they're COPD, etc. This probably takes me a little more than 5 min, esp if there are any "findings" or they have pain/ discomfort, but it's pretty quick and you get a wealth on info very rapidly. Works OK in real life. Your instructor may expect you to be more thorough than is realistic for the time constraint but get the assessment skills down first, then work on the timing.
  7. by   kimber1985
    As a student, I think I will appreciate listening in 5 places when I actually encounter a murmur. I think in the beginning you feel like "I have no idea what I am doing or looking for". I just had a patient with slow capillary refill. I was pressing on his nail beds like 5 times, then pressing my own to be sure. You feel like you are just going thru the motions until you catch something. Then you've got this time constraint balanced with being thorough. How much time should I spend on PERRLA with a guy who has a broken ankle? The doctor comes in and listens to the heart in couple of places and the lungs a couple of places and takes off. I've never seen a nurse flash a pen light in someones eye. I am a student, I do everything because that is my responsibility and I have the time. Its a good thing, but is it reality?
  8. by   cardiacRN2006
    Quote from kimber1985
    Its a good thing, but is it reality?
    Yes it is reality. I check pupils on every initial assessment, and with every subsequent assessment if their Dx supports that.


    I've had people with one blown pupil, or one oblong pupil before. It played no part in their Dx. But I have to chart the pupils on my flowsheet. If you don't check it, and you chart it, then you are lying.


    If something were to happen to the pt, (completely unrelated to the pupils), and you were to sit on the stand, you better believe that if you charted all day that your pts pupils were perrla and they weren't that it will make you look incompetent, or worse.

    They would question everything that you said and did, because you charted something that wasn't so.



    As far as the murmurs go, sometimes murmurs can ONLY be heard in one part. Sometimes they are so faint in the other parts, and then really obvious in only one location. So don't wait to hear a murmur to check all the areas. Besides, it takes like an extra 10 seconds to listen to the other areas.

    Again, if you chart that there were no murmurs, but the nurse before you and the nurse after you chart that there were, it only makes you look incompetent.

    It's a choice that you have to make as to what kind of nurse that you are going to be.
  9. by   upstate nynoonie
    No way a good accurate assessment takes about an hour
  10. by   upstate nynoonie
    :Melody: :Melody: I made the reply of an hour.
    I as a nurse for years, It takes about an hour vitals five minutes, skin check 20 minutes if unable too position, help is required you need too find an aide. Don't sell yourselves short or your residents, or patients.
    Asking your patients if capable thier history 20 minutes looking thru previous history in chart 20 minutes. Why take five minutes is a persons health worth only five minutes...
    Last edit by upstate nynoonie on Jan 28, '07 : Reason: abcs wrong
  11. by   greatan
    daytonite i was able to get on the site you requested a few days ago and it had some great info i need for my assessments but i can no longer get on the site you suggested. it gives me an error message. is there a similar site you can direct me to that gives each part of the head to toe along with the correct terminology to chart with?

    Quote from daytonite
    midcom. . .you accomplish it all by learning to multi-task. it takes time and experience. you'll get it eventually! here's the weblink you asked for:
    http://www.mededcenter.com/module_vi...+118#headtotoe



    here's a student clinical worksheet i've been working on. it includes review of systems information you might find helpful
  12. by   Daytonite
    i can't get into the site now either. sometimes places will take a file offline for a lot of different reasons. if there is one thing i've learned it's to copy a webpage and file it or copy and paste the text of it onto a document and save it so i always have it. i love pdf files because they can be easily saved on my computer and i can pull them up anytime i want. i am a part time student again myself and my instructors are always referring us to websites for information. i have one flash drive that i reserve specifically for my school work.

    check out the links on this thread. that wasn't the only resource for doing a head to toe assessment, just one that everyone seemed to like. you will find that a head to toe assessment is something that you have to customize to your own style over your time in practice. you will change the way you go about it in your beginning days/months/years until you are comfortable with what finally works for you. the main thing is that you hit all the important areas.
    http://allnurses.com/forums/f205/hea...ms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

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