brief head to toe assessment

mrsboots87 · Oct 12, 2014

A brief head to toe is likely a regular head to toe assessment as they take less than 15 minutes to perform in a willing patient. An in depth assessment would include a full neuro and other assessments. So honestly, worrying what is too much should not be in your thoughts. Just do a full head to toe because you need the practice.

Also keep in mind, our opinions on what a brief head to toe is really dont matter. The only person you can get the correct answer from is your instructor. Next clinical, just ask them what they expect done in your assessment.

mrsboots87 · Oct 12, 2014

Also, when in doubt always think ABC's. The rest of the assessment doesnt matter if the patient doesnt have a patent airway, isnt breathing, or has poor or no circulation. So that is always a good place to start.

havehope · Oct 12, 2014

I start from the top and work my way down (trust me, as time goes on you'll get better). I would always forget this or that, but now as I do them all the time it becomes easier. I inspect everything! Look in the ears, check the eyes with penlight, check mouth with penlight, I listen to everything at once-heart, lungs, bowel sounds, as I work my way down I check the pulses, etc.

Mosby's Pocket Guide for Health Assessment is an awesome book too, shows you EVERYTHING to look for,etc.

RN403, BSN, RN · Oct 12, 2014

Unless it is an admission or transfer I really do keep it brief and focused. I don't check pupil size or reactivity unless their condition indicates that I check.

Usually I do my assessment as follows:

Hello mr such and such I am RN403 and I will be your nurse today. I just wanted to do a quick assessment to make sure you're doing okay....I then assess for their orientation by asking them to state their name, where they are, and why they are there. It is never appropriate to assume a patient is oriented. They may seem oriented but upon assessing them you might find that they think they are at home. I have had the offgoing nurse tell me they are oriented only to find they were confused about where they were. It's important to assess this yourself!

I then go on to listen to lung sounds, bowel sounds, give the heart a quick listen, and check for normal pulses. I am an ortho nurse so I then look at the affected extremity, the dressing, and do neuro checks. I take a quick glance at the color and note the temp of their skin while doing my assessment.

I then ask about their IV site, give it a look, and ensure the proper fluids are running. Before I leave I ask about pain, nausea, and if the patient has any concerns or complaints. Then that completes my assessment. I modify this based on each patient's condition and focus the assessment as needed.

For example, if a patient were to have a GI issue you should do a more focused GI assessment or you should at least spend a little more time on this area to be sure you get a good assessment.

Also, if my patient has a foley, nasal cannula, blood hanging, a drain, etc. I modify my assessment so that I check for things that would pertain to that device such as skin breakdown behind the ears or in the nose, signs of an allergic reaction, and so on.

Basically, you just start from the head and move on down to the toes and assess what you see in between. It seems overwhelming at first but with time and practice you will perfect your assessment and pick up on abnormal findings. It just takes time. Best wishes.

mrsboots87 · Oct 12, 2014

Also remember that since you are in fundamentals a complete head to toe is usually required because you are still learning them. Even on a med/surg floor, you are a student and need to learn the whole thing, not just a focus as would be done by actual nurses. Im in block 2 and we are still required to do a head to toe on our patients for practice. We dont get to do just focused assessments until next semester I believe. I still miss things sometimes on my assessment that I have to go back for and I have done them quite a few times. So practice makes perfect. Even if you arent required to do a full head to toe, I would suggest doing it anyway.

hkqueenx3 · Oct 15, 2014

Wow, thank you everyone. I appreciate all your posts. I guess you're right, I should practice the whole thing! However there are some parts of the full head to toe that my professors don't want us to do. Probably for later next time. As of now they say they only want a brief one, but I'll do the best I can with these given tips. Thanks so much all!

StudentOfHealing · Oct 17, 2014

Follow something like a template.

Pt is a 50 year old male admitted with small bowel obstruction. He is A&OX4. PERRLA @ 3mm bilaterally. Swallowing mechanism intact. Gag reflex intact. Negative for JVD. Upon auscultation S1 and S2 present. Anterior & Posterior Lung sound present and clear bilaterally. Bowel sounds present in all quadrants. Abd soft and non-tender. Last BM per pt was10/16/14 and passing gas. Foley present. UOP @ 150. Bilaterally Pedal pulses +2. Cap refil

Pretty sure I missed something. This is a pretty basic assessment. Just add any differentials. Like if they're on oxygen. If they have a JP drain describe the site and dressing. Identify the output. If they have a PCA pump state the settings. If they have a hemovac ... likewise. If they have any dressing or drains talk about them. If they had a R kneee surgery you better hone in on that R neurovascular check. If they're fresh from surgery check their nausea. If they have telemetry going mention their rhythm and tele box number. Remember equipment and family is part of the assessment as well.

NurseGirl525, ASN, RN · Oct 17, 2014

It's a head to toe assessment so start at the head and work your way down. The whole time you are assessing skin integrity. I started at the top of the head and did hair then the ears. I went to the eyes, nose and mouth. You need to note whether or not everything is symmetrical, PERRLA with the eyes, nystygmus. Patency with the nose. Go to the neck. Palpate lymph nodes. Get carotid pulses and listen for Bruits. Also get temporal pulses. Are they strong? Even with temporal? Check midline trach. Then I get anterior chest sounds. I get heart sounds. I ascultate the stomach than palpate. Then I listen to posterior chest sounds. I check ROM on arms and check radial pulses. Then I am down to legs. Check ROM and pedal pulses. I also in the arms check for capillary refill on all finger and check capillary refill on all toes. Assess heels. Check for edema.

This sounds like a lot but when you do it, it's actually only about 10 minutes. We got sheets on what to include but we could do it in a order that felt good to us as long as we went head to toe. We also got our vital signs ahead of time. So if you need to get vital signs during the assessment I would do that first, in case anything is out of whack there.

Hope this helps.