Any tips on doing a head to toe assessment?

Purple_roses · Oct 29, 2015

These are great questions! I'm looking forward to seeing responses as I'm new at this as well.

As far as respirations go: when I'm taking my patient's vitals, I place my steth on the left side of his/her chest to get a pulse rate. I do this for 30 seconds. I keep my steth there for another 30 while I listen/feel for respirations. My instructor said this was acceptable.

Farawyn · Oct 29, 2015

These are good questions.

Do you need to assess PERRLA as per your instructor on every patient?

Counting respirations was tricky at first. I remember taking a radial pulse with one hand and actually counting the RR out on the other.

I hate to say that lots if this becomes second nature.

It takes time.

The more you do it, the easier it will be. Good luck!

allnurses Guide · Oct 29, 2015

Many stethescopes are too big to slide under the side of a pt, but the little cheap ones they use for isolation rooms (throw aways) are nearly flat, you can gently slide one between your fingers, under from the side without lifting the pt. You won't be able to go all the way under (to the spine), but you can get a fairly decent listen to the lower edges of the posterior lobes. This is where you have to hold very still, so as not to confuse the sound of sheets rubbing on the diaphragm back with actual breath sounds.

Flick the light at the eyes, don't shine steadily, look for a reaction. Have the pt stare at your nose, so the pupils are fixed in one place, easier to assess.

Bowel sounds are easily transmitted up, the question is, did the wet sound continue in the lungs with respirations or was it a one time sound. If someone is that wet, the sound will continue; if it is bowel related, likely only the one time noise is going to be heard, or an irregular pattern of noises. Lung sounds tend to be consistent with respiratory rhythm; although several deep breaths can clear up crackles and early morning noise from not having moved around much.

Bowel sounds may be anywhere from 1-15 in 30 seconds, most of the time you will only hear a few gurgles, and have to wait for that. Continuous noise would be hyperactive, but think of it in relation to oral intake. Obviously more noises when having just eaten or drinking large amounts because peristalsis is being stimulated, or a gut that is really empty and asking for food! Be sure to listen before palpating in order to get the actual peristalsis activity, rather than what you stirred up with palpation.

Counting resps can be really subtle. Getting people to stay quiet long enough to count is a challenge, so doing it during a pulse count is good, "hold on a second while I count here". You can even get to the point of counting pulse and resps at the same time, I use the numbers in my head for pulse, and count resps on my fingers (just move your thumb with each breath between each joint at a time on the fingers, 1/2/3 on index, 4/5/6/ on next (look at your hands, there are 12 spots on the 4 fingers to count on). Don't try to do a number, just move the thumb with each resp, and count them after you've calculated the pulse in your head, look down to see how many resps were done during that 15 or 30 seconds and go from there. If people know you are looking at resps, they become self conscious and may change their pattern without knowing they are doing it. During the days of glass thermometers it made it easy, just leave the thing in until you were done counting resps, alas for the old days......

hope that helps

Girlafraid13 · Oct 29, 2015

There's clips of lung sounds on YouTube. I found it very helpful

Teri123 · Oct 30, 2015

For respirations... I always took the radial pulse and then layed the arm on the patient stomach as if I'm still doing pulse but since I'm on top of them now I can feel the body rise up and down and can count without looking like I'm counting breathing

Tex. · Oct 30, 2015

Breath Sounds - A Guide to Auscultating Breath Sounds

allnurses Guide · Oct 31, 2015

For respirations... I always took the radial pulse and then layed the arm on the patient stomach as if I'm still doing pulse but since I'm on top of them now I can feel the body rise up and down and can count without looking like I'm counting breathing

touching the patient changes breathing patterns, just as being self conscious does

barcode120x, RN, NP · Oct 31, 2015

During my critical care class with an RT instructor, he mentioned that if you are unable to listen to the patient's back due to reasons that would cause difficulty or harm, don't do it. Just listen to the front. Always check the orders on how to move/turn a spinal patient and IF you are allowed to. In general, they need to turn so they don't get pressure ulcers and this is usually done by log-rolling, so might as well listen when you are turning the patient.

Good question about hyperactive vs normal bowel sounds. When I listen to each quadrant and I hear constant noises, I'll label that hyperactive. If it's like a noise, noise, pause, noise, pause, then I will label normal bowel sounds.

But yeah, you'll eventually get good AND fast at your head to toe. When I first started working (like literally a month ago) I was SUPER slow at the head to toe + charting. Once you get the hang of your facility's charting system and what they want in the system, it's quite simple and fast.

Pinkfleud · Nov 1, 2015

Great questions.

Try this site Over 100 Heart and Lung Sounds | Easy Auscultation it's the best one I've found yet. It gives normal and abnormal heart, lung, bruits etc..