Tips on head to toe assessments?

  1. 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 then were expected to do it on clinical day. I am completely new to nursing. Never had experience in a hospital and not good with new situations or being outgoing, so I get anxiety about doing everything right. I felt kind of stuck, not knowing what I should do next, etc. I felt awkward and clumsy. I didn't have a ton to write in my assessment; I forgot some things and left other areas blank because I wasn't sure how/if I should do that part of the assessment. Of course I got a lot written up by my instructor and felt like a failure. It wasn't just because of what she said that made me feel that way; I had already started feeling like I was doing a bad job and it just kind of cemented it for me, leaving me wondering if I'm going to be a terrible nurse. So...lots of anxiety right now and feeling overwhelmed. Hope you all can offer me some great tips and advice. Thanks!!!
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  2. 22 Comments

  3. by   HermioneG
    I created this method for the students at my school. Its based on the idea that the head to toe assessment is very organized and systematic, and that at the most basic level each system has just 3 things to assess. I call it the "Rule of 3s"

    Practice it in a very systematic way. Go in the exact same sequence every single time until you know it like the back of your hand and its second nature to you. After that, you can build off of it, or add in a focused assessment based on chief complaint.

    This might "out" me to a couple of people if they see this post since I've shared it with others, but meh the benefits outweigh the risks. Hope you find it helpful and let me know if you have any questions at all.

    Head to Toe "Rule of 3's"


    Intro:
    1. Introduction
    2. Wash hands
    3. ID band check

    Orientation:
    1. Person
    2. Place
    3. Time

    Face:
    1. Eyes
    2. Mouth
    3. Skin

    Heart:
    1. Inspect upper chest
    2. Auscultate w/diaphragm
    3. Auscultate w/bell

    Lungs:
    1. Inspect lower chest
    2. Auscultate on front
    3. Auscultate on back

    Abdomen:
    1. Inspect
    2. Auscultate
    3. Palpate

    Legs:
    1. Skin
    2. Appearance (Edema? Abnormalities?)
    3. Temp

    Feet:
    1. Pulse
    2. Capillary Refill
    3. Strength (dorsiflex, plantarflex)


    Arms:
    1. Skin
    2. Appearance
    3. Temp

    Hands:
    1. Pulse
    2. Capillary Refill
    3. Strength (grips)

    IV/drains:
    1. Rate
    2. Infiltration?
    3. Patency (flush with saline)

    Back (assess for):
    1. Skin
    2. Appearance/Muscles
    3. Temp

    Back (3 landmarks for skin breakdown):
    1. Occipital
    2. Sacral
    3. Heels

    Closing:
    1. Recap (Okay so I've finished your head to toe assessment…)
    2. Questions/Concerns (Do you have any questions or concerns?)
    3. Need Anything (Is there anything that I can get for you such as another blanket or some water?)
  4. by   Castiela
    Practice makes perfect? Do you have a friend in the program or a family member you can practice doing head to toes on while referencing a cheat sheet? My husband could almost recite the head to toe assessment as well as I could because I practiced him so often.

    You will find your flow as you practice this skill more and find a way to make it your own. I still miss Things occasionally and have to run to the room to get a piece of data. You'll also find you'll be able to group things and gather information without it seeming like you are. For example, just talking to a patient, you've assessed how their breathing is, their orientation and demeanour. I check my patients skin while doing washes.etc.

    Best of luck
  5. by   Gods_nurse
    Great post!!
    Love the "rules of 3"
  6. by   HarleyGrandma
    My biggest piece of advice is remember that this is all new, and it will feel uncomfortable, and if you knew what to do you wouldn't be in school! Try to learn several new things each day, research what you missed and commit to not missing that item next time. Lather, rinse, repeat. Forever.
    Learning requires you to step outside your comfort zone, way outside your comfort zone. That icky stretching feeling? It's you growing :-)
  7. by   NightNerd
    It takes a lot of repetition. You will get it down with practice. Definitely organise by sections, and maybe try grouping a couple things at a time when just practicing at home or whatever. For example, I always used to miss stuff doing neuro checks, so I practiced doing a few of those on my own, without the rest of the body systems, and now I can seamlessly add it into the rest of my assessment. Also, getting familiar with the documentation system you'll be using can be a trigger for remembering most, if not all, of what to look for. While your assessment isn't totally driven by what you need to document, it can definitely help you recall a few things while you're at the bedside.
  8. by   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!!!
    Last edit by Philly85 on Oct 29
  9. by   HermioneG
    Quote from Gods_nurse
    Great post!!
    Love the "rules of 3"
    That makes me really happy I really do hope that it can end up helping more people than I'll ever know!
  10. by   aquakenn
    I like your detail!!
  11. by   Elfriede
    "rules of 3" are easy to understand, to apply and to translate.
    Bought. Thanks a lot. Frieda
  12. by   hopeful_meg
    Student nurse here! I feel your pain but I promise that it absolutely does get better after practice practice practice. Practice on your parents, siblings, friends, and anyone else that will let you assess them. The more times you do it, the more you will feel confident in your skills.

    Second thing... And I know you didn't ask how to deal with it, but you mentioned it so.. Breathe deep before you go into the patients rooms, and then cut yourself a little slack. You're going to screw up and that is perfectly fine. Take your assessment sheet with you and take it slow. You aren't going to remember everything anyway and you need to write your findings down. Make sure you fill in your spots. Watch YouTube for nursing assessments to get a feel of the flow.
  13. by   Elven_Girl
    Yes, I have had my husband pretend to be my patient and I'm sure it will be happening much more! Great advice, thanks!
  14. by   Elven_Girl
    Quote from hopeful_meg
    Student nurse here! I feel your pain but I promise that it absolutely does get better after practice practice practice. Practice on your parents, siblings, friends, and anyone else that will let you assess them. The more times you do it, the more you will feel confident in your skills.

    Second thing... And I know you didn't ask how to deal with it, but you mentioned it so.. Breathe deep before you go into the patients rooms, and then cut yourself a little slack. You're going to screw up and that is perfectly fine. Take your assessment sheet with you and take it slow. You aren't going to remember everything anyway and you need to write your findings down. Make sure you fill in your spots. Watch YouTube for nursing assessments to get a feel of the flow.
    Thanks so much for this great advice! I have had my husband pretend to be my patient, and I'm sure it will be happening much more! Breathing deeply is definitely something I need to be doing. 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.

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