how to do client's head to toe assessment

bluegeegoo2, LPN · Mar 12, 2008

Start with the head. Look at the scalp, shape of head, note any abnormalites. (I.e. lumps, bumps, scrapes, anything that is not "normal"). Then look at the eyes, use your pen light to check for equal pupil dilation, time of response, size of pupils, any problems with the conjunctiva. Note any redness, yellowness, dryness, unequal pupil size, unequal dilation, etc. Next is the nose: Is it running, are they sniffling, complaining of dry sinus...then check the teeth, note their condition, lack of, condition of, look for any sores, open areas, dryness/moistness, ability to swallow/speak. All the while, whatever part your on, always note condition of the skin. Note any abnormality. Remember: You're comparing your patients' condition to a "perfect" example of a human being. Move to the neck, have them perform range of motion. Can they turn their head, hold it up on their own? Look at the arms, have them perform range of motion and note if they have pain moving parts or limited ROM. Listen to the lungs and note any adventitious lung sounds, diminished/absent sounds (some folks have had a lung or part of a lung removed, therefore will have no breath sounds in that area), and note abnormalites. While your listening to their breath sounds on their back, go ahead and assess their as well. Note if they have a kyphosis (hump back), if their spine is straight, and always ask if they have pain in any part your assessing. Ask what brings it on, how long it tends to last, and what (if anything) makes it better. I.e. positioning, heat, meds, etc. On to the abdomen. check for bowel sounds in all 4 quads, note if they are hyper/hypo, palpate gently for any masses, hardness, and watch them for guarding. That's always a good sign something is going on in there. Ask about bladder/bowels habits, if they are contient/incontient, when they last had a BM, if they use laxatives/stool softeners, etc. ALWAYS check the peri area, buttocks, and coccyx, as these are great areas to find skin issues. Perform ROM on the legs, one at a time, and assess for pain, limited ROM. Make sure to check their feet thoroughly, in between toes, especially if they are diabetic or have circulation problems. I almost forgot to mention assess their cognitive function. Are they oriented to person/place/time? How's their memory? What are their eating/drinking habits? Preferences? I'm sure I'm forgetting something important, but it's been awhile since I've done a full comprehensive head-to-toe. I hope this helps.

bluegeegoo2, LPN · Mar 12, 2008

Heart tones!!!! I forgot heart tones. Note for irregular rhythm, extra beats, murmurs, and if you hear a clicking sound, they have a valve replacement. Always do vitals first. Once you've flipped them over a time or two, their values will have changed from their baseline norm. Thanks for the post. I needed to go over that again myself!!

darshana · Mar 12, 2008

Thank you so much for help me out bluegeegoo2

Darshana.

darshana · Mar 12, 2008

Hi everyone:heartbeat

I need to know how to start interview with the client with openended

Question and closeended Question. Please any one help me i have a exam this week.

Thank you

Darshana.:heartbeat

Fiona59 · Mar 13, 2008

This really isn't the homework hotline.

You need to follow the programme modules for your course. The modules used by college outlined all of this. Read them, listen to your instructors, most are really good at using open-ended questions in the classroom setting.

shorthair WI · Mar 16, 2008

Start with the head. Look at the scalp, shape of head, note any abnormalites. (I.e. lumps, bumps, scrapes, anything that is not "normal"). Then look at the eyes, use your pen light to check for equal pupil dilation, time of response, size of pupils, any problems with the conjunctiva. Note any redness, yellowness, dryness, unequal pupil size, unequal dilation, etc. Next is the nose: Is it running, are they sniffling, complaining of dry sinus...then check the teeth, note their condition, lack of, condition of, look for any sores, open areas, dryness/moistness, ability to swallow/speak. All the while, whatever part your on, always note condition of the skin. Note any abnormality. Remember: You're comparing your patients' condition to a "perfect" example of a human being. Move to the neck, have them perform range of motion. Can they turn their head, hold it up on their own? Look at the arms, have them perform range of motion and note if they have pain moving parts or limited ROM. Listen to the lungs and note any adventitious lung sounds, diminished/absent sounds (some folks have had a lung or part of a lung removed, therefore will have no breath sounds in that area), and note abnormalites. While your listening to their breath sounds on their back, go ahead and assess their as well. Note if they have a kyphosis (hump back), if their spine is straight, and always ask if they have pain in any part your assessing. Ask what brings it on, how long it tends to last, and what (if anything) makes it better. I.e. positioning, heat, meds, etc. On to the abdomen. check for bowel sounds in all 4 quads, note if they are hyper/hypo, palpate gently for any masses, hardness, and watch them for guarding. That's always a good sign something is going on in there. Ask about bladder/bowels habits, if they are contient/incontient, when they last had a BM, if they use laxatives/stool softeners, etc. ALWAYS check the peri area, buttocks, and coccyx, as these are great areas to find skin issues. Perform ROM on the legs, one at a time, and assess for pain, limited ROM. Make sure to check their feet thoroughly, in between toes, especially if they are diabetic or have circulation problems. I almost forgot to mention assess their cognitive function. Are they oriented to person/place/time? How's their memory? What are their eating/drinking habits? Preferences? I'm sure I'm forgetting something important, but it's been awhile since I've done a full comprehensive head-to-toe. I hope this helps.

Well done, but be sure to mention the cranial nerves and their function/findings.

SHWI.

bluegeegoo2, LPN · Mar 16, 2008

I KNEW I forgot something important!!!!

TheCommuter, BSN, RN · Mar 18, 2008

Moved to the Nursing Student Assistance forum.

nurz2be · Mar 18, 2008

IT all depends on your client/patient. Once you have previewed the chart you already know if the person has any cognitive or physical impairments that might limit the ability to answer questions. The worst thing to do, in my opinion, is to start running down the list asking questions off the form. If you have time, and you engage your person, they will being answering questions without you asking any or limited questions. ALWAYS take their culture into consideration. Some cultures prefer the spouse to speak, some find it intrusive to ask questions in mixed gender company, some find it offensive to be asked questions by someone of the opposite sex. Be conscious of those things, talk to your client like you would want to be spoken to, and generally, that will help you. Before you ask a question, think, "Would I want someone asking me a question stated like that"?

I remember my first "interview" and I was so nervous before I went in. Once I started talking it really almost came naturally.

GOOD LUCK

Hi everyone:heartbeat
I need to know how to start interview with the client with openended
Question and closeended Question. Please any one help me i have a exam this week.
Thank you
Darshana.:heartbeat

Daytonite, BSN, RN · Mar 18, 2008

it's too bad you didn't originally post your question in this student forum where we could have gotten help to you much sooner. we have a specific thread with all kinds of assessment information on it. here is the link to it:

https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html - health assessment resources, techniques, and forms (in nursing student assistance forum)

darshana · Mar 19, 2008

Thank you so much all of you for help me out with my Head to Toe assessment. It helps lot.

Darshana.