Head to Toe Assessment

NurseCalamity · Jun 5, 2015

You start... head to toe lol. Then I chart in that fashion. Start with cognition. Your assessment should start as soon as you walk in the room. Hi, so and so I'm ____ I'll be your student nurse for today. Can I have your name? Go on to find out if they're oriented go place and time as well. How's their appetite and pain scale? Are they aphasic? PERRLA. Mucous membranes. Face symmetrical? Neck supple? Lung sounds? Heart sounds. Bowel sounds. Hand grasps. Edema? Pedal push. Pedal pulses present? It's easier to go in an orderly fashion.

Iris_kt · Jun 5, 2015

The best advice I can think of is keep practicing until you are comfortable. Try doing a head to toe assessment on someone at home or with another student. Give them a list and they can let you know at the end what you missed- this is probably better to do with a student so they know what to look for.

You mentioned the nurses not doing complete assessments. Their assessments are probably complete but they've just become really efficient.

PaulBaxter · Jun 5, 2015

My advice would be to find an assessment check list and bring it into the room with you. Then each time you use it, see how far you can get before you need to look at it.

It's better for both you and the patient to "cheat" with a list than to just skip a lot of things.

Hollyhocks720, MSN, NP · Jun 6, 2015

I would walk through it reading notes a few times, then set a voice recorder and talk through it, just faking the motions if you don't have a patient. Then play back the recording and check it against your notes. Keep doing that until you get it all.

NightWatch · Jun 6, 2015

This is my full head to toe assessment that I used during clinical. My instructor was able to do all of this in less than 10 minutes. I would probably take 10-15 minutes.

Neuro

LOC/AAO x3

balance/gait/coordination

sensory/thought process

PERRLA

Cranial Nerves: symmetry, tone,pain

Cardiac

heart sounds, pulses

capillary refill, perfusion

ekg

edema

laboratory

blood pressure

skin temperature

Pulmonary

breath sounds

respiratory rate and effort

depth/symmetry

coughing

sputum

spO2

blood gases

use of O2 delivery

Gastrointestinal

bowel sounds, appetite

abdomen: appearance, distention,masses

Last BM, difficulties

tubes and drain

NVD

I and O

Genitourinary

urinary frequency, characteristics

foley assessment

skin appearance

bladder distention

urinalysis

I and O

LMP

IV Assessments

check surrounding skin

check IV fluids running in, checkpatency flush and pull back

check correct IV fluid and rate

Check IV tubing date, dressing,intactness

check awareness of IV

Skin issues

back

moistness

MendedHeart · Jun 6, 2015

Don't forget psychosocial. ðŸ˜†

psu_213, BSN, RN · Jun 6, 2015

There is a possibility the nurses are doing a focused assessment. Unless it is a new admit to the unit, this is usually what is done (with some exceptions, including the ICU). For example, you are not going to assess every cranial nerve on a patient who is admitted with a non-neuro problem. In school, they may demand that you do a full head-to-toe on every patient--and it is easiest if you truly move from head to toe.

Also, as others have hinted, nurses learn to multitask. For example, your introduction to the patient alone gives you a lot of your neuro assessment. Just from observing the patient you learn much of the rest of the information--facial symmetry, cognition, etc. As you go through other assessments, you complete the rest of it. When you assess for edema/pedal pulses/cap refill, you will also assess for sensation and movement in the legs.

Rather than saying you are doing a "cardiac" assessment and a "pulmonary" assessment, you would be doing a "chest" assessment. Rather than listen to lungs, assess expansion, etc. then move on to listen to heart sounds, etc., you cover both at the same time in your assessment (i.e. listen to the heart on the front of the chest, then move right on to listen the lungs on the back on the chest). This comes with experience, but eventually your assessment of systems meld together and you "cluster" the steps in your assessment.

wanderlustnurse88, RN · Jun 6, 2015

This is my full head to toe assessment that I used during clinical. My instructor was able to do all of this in less than 10 minutes. I would probably take 10-15 minutes.
Neuro
LOC/AAO x3
balance/gait/coordination
sensory/thought process
PERRLA
Cranial Nerves: symmetry, tone,pain
Cardiac
heart sounds, pulses
capillary refill, perfusion
ekg
edema
laboratory
blood pressure
skin temperature
Pulmonary
breath sounds
respiratory rate and effort
depth/symmetry
coughing
sputum
spO2
blood gases
use of O2 delivery
Gastrointestinal
bowel sounds, appetite
abdomen: appearance, distention,masses
Last BM, difficulties
tubes and drain
NVD
I and O
Genitourinary
urinary frequency, characteristics
foley assessment
skin appearance
bladder distention
urinalysis
I and O
LMP
IV Assessments
check surrounding skin
check IV fluids running in, checkpatency flush and pull back
check correct IV fluid and rate
Check IV tubing date, dressing,intactness
check awareness of IV
Skin issues
back
moistness

That is quite an extensive list. In practice you won't be doing such an in depth assessment unless they are a new admit or it is ICU. I tend to do a focused assessment due to why they are on my floor. There are things such as assess gait that if they are bed bound or already in bed for night shift that I won't do. Urinalysis is only done if you have an order or you think they might be brewing something. A lot of the pulmonary system you are assessing while talking with the pt. Respiratory rate, cough, need for o2, coughing etc can all be noted while talking with the pt when you enter the room.

Spangle Brown · Jun 7, 2015

I have a form that our professors had use fill out. It has places for 3 assessments. I keep it in my pocket and use it to write down information for charting. As I write info down, I am quickly reviewing the form for things I might be forgetting. The more I do, the less that happens. The first time I used it, not only was it reminding me of what I need to do, I was able to quickly mark the information down.

Pistachio830 · Jun 7, 2015

I used to practice on my teddy bear over and over to make sure I didn't miss anything. And if I did miss anything (on my patient at the hospital) I would go back and ask and or assess.

nurseprnRN, BSN, RN · Jun 8, 2015

This is also an excellent argument for some aspects of primary nursing, i.e., don't turf off bed baths to the CNA. You can assess just about all of this except the stuff you need a stethoscope for in the course of doing a bath. You make conversation, and although it sounds informal and off the cuff, it's very focused. You listen to the person's answers, check movement, range of motion, ability to follow directions, skin condition, edema, pulses, all that as you move smoothly along. You ask those four critical questions that predict successful discharge: How may steps to go up to get into your / apartment? Do you have a way to fill your prescriptions? Can you get to your PCP? Who shops and cooks for you? Multitasking is good.