head to toe

Disablednurse · Jul 22, 2003

When I was the admissions nurse in LTC, we always had to do a head to toe assessment on all admissions. What I did was just start at the head and work my way down. Everything that had to do with the head, eyes, pupils, ears, mouth, teeth, mental acuity, etc, then the trunk, bruises, sores, heart, lungs, etc, then the extremities, arms first, to include grip, ROM with each area, neck goes with the head, then the legs. With the legs, you assess ability to stand, balance, condition of feet, pulses, ROM, etc. If you follow this pattern, it is very hard to forget or leave out anything. If you need to, sometimes, sit down and make you a cheat note, listing everything that you will be needing to assess when you do a head to toe assessment. I was told by the other departments that they really liked my assessments because it made their jobs a lot easier because I covered everything in mine.

RNIAM, BSN, RN · Jul 22, 2003

There is a book called the three minute assessment. I really haven't had a chance to look through it completely but it seems to have alot of good information in it.

det01 · Jul 22, 2003

. What I did was just start at the head and work my way down.
This is how I did it. My partner and I memorized it this way. We did it in a way that caused the "patient" (each other) to have to move as little as possible. Some teachers take off points if you make the "patient" get up and down too much.
I made notecards of what to do at each place. (You will need the larger sized notecards) If your teacher allows it, you can check several crainial nerves at once by asking the patient to perform simple tasks. Also - do not forget to wash your hands before the assessment!
Doing it the way I did - I got a 98!
(I was slightly off of where I palpated the dorsalis pedias pulse and I forgot to mention I saw the cone of light when examining the inside of the ear)

NurseDianne, ADN · Jul 22, 2003

thanks ya'll........i've got this check off at 8 AM tomorrow........and i just am in a funk........i think i'm tired!! our finals are thursday and friday.......assessment thurs (i have an A so far) and transistion on friday (i have a B).........i'm just sooooooooooooooooooooooooooooooooo tired!!

jschut, BSN, RN · Jul 23, 2003

So? How'd you do?

Did you do the head to toe just as it's said? "Head to toe"?

Hang in there.....you're gonna make it!

Julie:)