Head to Toe Assessments?

[Tree2144]

Hello all,

I received my first patient assignment the other day (geriatric patient). I have been doing research on his condition, illness, meds....etc. I have to do my first head to toe assessment on Tuesday and I am sooooooo nervous. I feel like I will forget everything that I have learned and will choke miserably!!!!! I want to do my assessment in a way that has minimal movement for the patient, but things are getting jumbled in my head. I need an assessment that is quick, but thorough.:uhoh21:

This is my greatest fear.....any advice? How to keep it simple and short? How to get over the anxiety?

Student Vocational Nurse in my 1st. Semester looking for advice...Thanks!

[Fiona59]

Start at the head and work your way down the body. You can assess skin condition and mobility while you are doing the eyes, ears, etc. Just remember to remove hearing aides a couple of minutes prior to taking typmanic temps.

If the patient is in bed will you need a second pair of hands to turn him/her to examine their backs and listen to posterior lung sounds.

Oh, and don't forget to take a towel or folded sheet in with you to cover exposed genitals/breasts. Instructors like it (and too many nurses forget) to respect the patients dignity and privacy.

Its not as hard as you think it will be. Can you practice on a spouse or sig. other this weekend??

[LPNer]

The way I remember to cover my bases when doing a head to toe is to, of course, start at the head and think of each system in the area I am working with.

Overall

• Appearance, grossly obese, emaciated, dirty, etc
  
• Odors, urine, stool, BO, fruity, etc
  
• What do they sound like? Or did they speak at all?
  
• Position/posture
  
• Skin color/texture
  

Head

• CNS
  
• Auditory
  
• Vision
  
• Smell (their nose, not mine)
  
• condition of hair? very dry/oily (may or may not "be something" make a mental note)
  

Neck

• condition of trach - midline?
  
• audible breathing sounds (not using steth for lung sounds)
  
• C/O (above for head too)
  
• pulses
  

Torso:

• Chest
  
  • lung sounds
    
  • symetry on inspration/experation
    
  • depth of resperation
    
  • C/O
    
  • etc
    
  • etc
    
  • etc all the way down
    

  [*]Abdomen

  [*]Back

Perinium

Upper Extremities

Lower Extremities

For each of the areas I inspect/assess I think of all the systems available for input into the system. With very little practice, it will come to you very quickly and you will start seeing abdomens as a wealth of information instead of just the GI tract. I havn't seen this outlined since nursing school nearly 30 years ago (much better outline than I gave you, I left you with lots of blanks to fill in, but I didn't think I needed to write it because you know what to look at) and since then I have developed an excellent assessment strategy.