Tips on head to toe assessments? - page 2

Hi everyone! I would really love some advice on how to do a smooth, organized head to toe assessment on a pt. We had just went over it on lecture 2 days before clinical and lab 1 day before, and... Read More

  1. by   Elven_Girl
    Quote from Philly85
    Ugh, the dreaded head to toe. Please know that you are not alone. When I started my first clinical, those very words would fill me with ice-cold fear. It absolutely DOES get better with practice, you really just need to push through it and develop a consistent system that you do the same way EVERY time and never deviate from.

    I'm still in nursing school (a little more than halfway through), but this is basically what I do from time of intro through head to toe:

    Walk into room: Hi, I'm Philly85, I'm a student nurse from So and So University. I'll be helping out Nurse So and So with your care until 7 pm tonight. How are you feeling? (Respond appropriately to their answer and have general 1-2 minute convo to build a rapport). Is there anything I can get you right now? OK, I'll go ahead and grab that for you. Would it be all right if I get your vitals and do a quick assessment on you when I come back? Ok, great, I'll be right back.

    AND ACTUALLY COME BACK SHORTLY - DON'T GO HIDE IN THE BATHROOM FOR 30 MINUTES FREAKING OUT ABOUT HOW YOU ARE GOING TO DO YOUR ASSESSMENT (yes, I did this several times in the beginning, lol...)

    Get them whatever they need, come back (hand hygiene before coming into the room) and give them whatever was requested. Putting on gloves as you say --> "OK, as I mentioned earlier, I'm just going to get your vitals and do a quick assessment. Can you tell me your name and DOB? (Verify what they state matches wristband). --> Don't ask them if it's still a good time (unless they are eating breakfast or something). If you do, they might put it off, etc. You need to get your assessment done, the sooner the better.

    Get vitals, including pain level (I'm assuming you can do this by now)

    Neuro:

    AAO x 3: You may have already determined their status just by having that 1-2 minute convo with them when you first entered the room. If not, then just ask the basic questions. "Can you tell me your nurse's name or my name (don't ask them their own name, that is too easy and is not a good indicator of if they are actually oriented to person), do you know where you are/what floor you're on, what is today's date/who is the president?)

    PERRLA using penlight. Cardinal fields of gaze if not already determined by simply seeing that their eyes tracked you easily throughout the room previously.

    CV: Auscultate heart sounds at all five points with diaphragm and bell - Apical heart rate if you are feeling fancy

    Pulm: Anterior/Posterior Breath sounds

    GI: Auscultate bowel sounds FIRST, then palpate

    Now all of your stethoscope stuff is done

    Check B/L radial pulses for amplitude, cap refill on index fingers, and upper extremity strength testing

    Skin: You've already been assessing the skin up until this point with everything you've been doing, but now lift up blanket and inspect the lower extremities. Feel for skin temp with backs of hands going down their shins, then check for edema with thumbs going down their shins again.

    Check pedal pulses, cap refill on big toes, heels for skin breakdown, lower extremity strength testing.

    "OK, everything looks good" (if it does), or if something is off, let them know, but that you will have their nurse come and take a look.

    "Thank you for letting me do your assessment, is there anything else I can get you? No? OK, well we'll be back in at 8 am to give you your morning meds."

    If they are incontinent, check their skin for breakdown whenever you change them. Don't let the CNA's do it all the time, you need to get in there to make sure you are assessing.

    If not incontinent, they are more likely to be up and walking or getting onto a commode. Check their posterior skin if you are up and walking them/assisting them during these times.

    Seems to work pretty well for me, anyway. Some people like to stick strictly with the systems and go back up and down the body (strength testing all at once, cap refills all at once, pulses all at once, etc), but I find it much easier to literally stick to HEAD TO TOE - otherwise I forget stuff.

    P.S. - Now is also a good time to ask them if they'd like to move from bed to chair for a little while (maybe have breakfast in the chair while watching the morning news?). Help them change into a new gown once in the chair. Then change the bed linens and spruce up the room a little bit.

    P.P.S. - This may not all work out as perfectly as the above, but the key is to get in there and get this done AS SOON AS POSSIBLE. There's nothing worse as a student nurse than the feeling of knowing that you still haven't done your assessment on your patient and you are putting it off b/c you are too afraid. Just get in there and do it. And then CHART IT in the computer if your site allows you to do so as a student. Don't worry, your nurse will be doing her OWN assessment and will be charting that as well, so you won't be "messing anything up."

    It may not be perfect, but usually patients are very understanding that you are a student and are learning. The more you do it, the better you'll become.

    Good luck!!!
    Thanks! This is great. You have a systematic system that may help me!
  2. by   nursemike
    Quote from HermioneG
    That makes me really happy I really do hope that it can end up helping more people than I'll ever know!
    I've been practicing for 12 years. I still find your Rules of 3 a useful tool. Being succinct has never been my strong suit.
  3. by   Elven_Girl
    Quote from nursemike
    I've been practicing for 12 years. I still find your Rules of 3 a useful tool. Being succinct has never been my strong suit.
    This is so good to know! I feel a bit relieved too to know that I'm not the only one who isn't always succinct. I'm definitely going to be looking into this method more!
  4. by   katyq82
    Quote from Elven_Girl
    I also agree that I should take my form in; it's hard for me to remember everything on there! My instructor told us it's frowned upon to be writing on it in the room...but I find it very helpful to be able to.
    Everyone has to write things down! I agree that you don't want to be using your form like a teleprompter and be lost without it, but you will need to jot down notes about what you find or else you may forget an important detail.
  5. by   nursemike
    One hectic night, early in my career, I told my charge nurse that the only way I could get my assessments done would be to assess another system each time I put a patient back in bed, then stitch them all together when I charted. He gave me a slug on the shoulder and said, "now you're thinking like a nurse!" In the real world, you do have to improvise, at times, but it's important to have a solid foundation in the basics.
  6. by   Snowdin
    Thank you very much for sharing the methods of "Head to Toe - Rules of 3". I think that it will help a lot!
  7. by   HermioneG
    Quote from nursemike
    I've been practicing for 12 years. I still find your Rules of 3 a useful tool. Being succinct has never been my strong suit.
    This makes me so happy, thank you!!!
  8. by   HermioneG
    Quote from Snowdin
    Thank you very much for sharing the methods of "Head to Toe - Rules of 3". I think that it will help a lot!
    Thanks!! the positive feedback I got here inspired me and i ended up submitting it as an article so hopefully it can help more people! Its not perfect, but it has really helped me in my own personal practice.
  9. by   InfirmiereMaybe
    Quote from HermioneG
    That makes me really happy I really do hope that it can end up helping more people than I'll ever know!
    I have a head to toe practicum next week. Thanks for sharing.
  10. by   al3x117
    As dumb as this sounds just go from head to toe. What we had to do is video ourselves over and over and over again in skills lab. We rewatched every single video and were critical to each other over things that we missed to check on our patients. I will tell you though I can do a full head to toe no problem right now. I would advise you to not look at the check sheets that is the real trick. Do it from making your own sheet and break each body system with the assessment piece. Such as head = pupils, JVD, battle signs (bruising behind the ears), tongue movements, lympth nodes, tracheal deviation, looking inside the ears at the tympanic membrane for any s/s drainage and inflammation, etc. Then move onto chest = lung sounds, palpation, percussion, chest expansion, diaphragmatic excursion, etc. And then do that for every body system. I would write this stuff down on a huge white board if you have it and then do the full assessment over and over and over again. You will get better at this don't worry but you have to practice.

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