Need Advice on Head to Toe Assessments

letina · Mar 26, 2006

Is this of any help?........

http://www.mededcenter.com/module_viewer.asp?module=+118

BoonersmomRN · Mar 26, 2006

This is how I do mine...if it helps. First I read the chart + kardex so I have an idea of what to expect..so when I do my snapshot I know what to look for. I fill out any pertinent info from the chart. I write down their meds- look them up.

Go in..do snapshot. Make sure everything is what it was supposed to be- if not, report it.

Take vitals. As I am taking vitals ( and jotting down #'s) I am asking question to assess their cognitive level....are they alert? if not..what level are they? oriented X3? X2? X1? Not at all? How is their speech? How is their attention span, etc. Are they being cooperative? What is their mood? As I am doing this I am also looking at their head and neck....is their hair shiny/course/falling out/etc. Are their facial movements and features symmetrical...if not what is abnormal, etc. Any visible lesions? Marks?

Then I typically move on to the bath where is when I knock out a HUGE portion. Ausculating lung fields, percussing lung fields- do they have a cough? is it productive? if so ..what color, etc is the sputum., asking about pain and assessing using the 0-10 scale..., , assessing skin- what color is it, is it warm/cool, how is the turgor? are there any lesions/ impaired integrity? scars? etc etc, how did the scalp look?is there any edema..if so what stage is it? listening to bowel sounds- are they hypo/hyper/norm...percuss...anything abnormal? palpate..anything abnormal? if so..what quadrant, what sound, etc, how is their ROM? What is their muscle strength? tone? any contractures? etc etc. Could I palpate the peripheral pulses? If no..where couldn't I? Did I use the doppler or get it manually? What is their cap refill? What do their nails look like? Any JVD?

If they are ambulatory - how ambulatory are they? any assisted devices? how is their gait? what is their ordered activity. If they are not ambulatory- why...etc

When I do oral care...assessing the mouth..any dentures? caries? What is the mucosa like? color? how does the tongue appear? any odor? Are their lips cracked? any lesions? Are their nares patent? Any drainage?

Assessing their breakfast- how many ML did they take in? What % of their food did they eat? What is the diet? Are they compliant? Are they on a tube? If so what kind? What diet was ordered? Any signs of under/over hydration?

Assessing their output- did they urinate? If so what was the amount, color, odor, clarity, etc. Did they have a bowel movement? If so same as above.

After this I have usually knocked out a huge chunk and then sit down to check for PERRLA., acuity..documenting if they have glasses/contacts/ is there a hearing aid? If so what ear? both?..checking to see if their thyroid is midline, etc

So basically I am jumping all around but it all comes together in the end run:). With time you will find you can knock out 2 systems at once ( you can do a neuro check as you are taking vitals..or doing the bath..etc etc)

MIA-RN1, RN · Mar 26, 2006

I start w/ vitals, then I do: Neuro check (eyes, grip, movements, orientation)

Lung sounds next, and that allows me to check skin on the back and buttocks when they roll over. Then heart and apical pulse. Then I do an extra minute to count resps without telling pt. so they don't breathe funny.

Then radial pulses, popliteal pulses if indicated, pedal pulses and check circ. in toes. Then I do Homan's and inspect the legs.

Next abdomen--IAPP--Inspect, Auscultate, percussion, palpation. (I always think : I Ate Purple People to remember)

That more or less covers it. If there is anything in their chart such as wounds, bandages, drains etc I check them next. Oh, and IV flushes with assessment too are a good habit to get done early in shift so you don't forget later.

blackdog · Mar 27, 2006

Thanks for all of the replies. They have all been significantly more helpful than what I was told by my instructors which was basically "you'll have to develop your own system". I feel much better now.

STRESSED SPN · Mar 28, 2006

Quick Easy Method That I Follow Is : Neurological = Level Of Consciouness Alert Drowsy, Lethargic, Oriented X 1ect.

Integumentary = Skin Coniditon Color Temp Turgor Tears Moist Cardiovascular= Pulse Strenth Cap Refill Pedal Pulses Edma Iv Site Condition Of Site Rate What Fluid Respiratory= O2 Rate Breath Sounds Resp Rate Adventious Breath Sounds Gastro= Peg Tube Condition Rate Of Feeding What Feeding Location Bowel Sounds +x 4 Abd Distenion Urinary = Color Odor Amount Freq Cath Size If You Are Interested I Will Give You A Sample Assessmet Just Private Message Me

Christian_SN, RN · Mar 28, 2006

use this format:

Orientation: person, place, time, and event. Are they awake, alert, and oriented?

Skin: Check turgor, edema od dependent areas, temp, moisture/dryness, capillary refill, color, lesions, hair distribution, campare R to L sides.

Head/Neck: note size, shape, symmetry of facial features; PERRLA; color of sclera/conjunctiva; palpate maxillary/frontal sinuses for tenderness; mucous membranes (moist, pink, intact); visualize pharynx and tonsils if indicated; tongue midline; palpate lymph nodes; check for JCD; apparatus (NG tubes, O2 mask, tracheostomy, etc)

Extremities: ROM bilaterally; strength of upper and lower extremities; pulses; sensation; Homan's sign; check for JVD; apparatus (IV's, restraints; dressings; drains)

Chest: Auscultate breath and heart sounds; note retractions or use of accessory muscles; note chest symmetry; palpate for masses; breat exam if indicated; apparatus (telemetry; chest tubes; CVP lines; dressings; drains)

Abdomen: note scars; herniations; bowel sounds in all 4 quadrants; palpate for massess and tenderness; is abdomen firm/sodft; CVA tenderness; apparatus (G tube; ostomy; dressings; drains)

Perineum: note drainage; hemorrhoids; apparatus (catheter)

Equipment: note all monitors and record readings (IV pumps and amt of fluid infused, solution, and rate of infusion; EKG readings; feeding pumps; etx)

Drains/Dressings: note site of dressing and amt of drainage; on catheters note amt of drainage and color of urine Doctor Visits: note who the doctor is, time of visit, what he/she did

Procedures: note all procedures performed and what time (catheters, NG tubtes, trach care, dressing changes, etc)

Safety: bed locked and in low position; HOB side rails x 2; call bell within reach)

Patient Complaints: document all complaints/statements in their words using quotations

then write: hope this example helps you ... my teachers also say i can tell you the amount of hairs on their head. hee hee... i have ALWAYS gotten an A for my head-to-toe and narr notes. i love to do them. let me know if you like?

0700

Received report from J RN to J RN at 0700. Side rails up x4, call light within reach, bed in low position and locked. HOB elevated to 30 degrees. Name/id, PCN allergy band on right lower arm with easy view. Admit to ER on 02/07/2006 due to SOB with dz of CHF. Lethargic LOC, A&Ox3 responsive to speech and does follow commands. R 3mm, L 3mm. PERRLA moist, pink, intact mucus membranes. Lips moist with Vaseline per md orders. No mouth order. Has majority of teeth, no loose teeth, no dentures. Swallowing and gag reflex intact. Does not have any hearing loss, thus no hearing aids. Does hear whispers bilaterally. Attempts to speak. GCS of 15 out of 15. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Morphine 2-5 mg IV Q4H or PRN per MD orders if needed for pain. Hand grips are equal bilaterally but weak. No tremors or seizures. Lorazepam 1 ml Q2H PRN per MD orders for sedation. Levothyroxine 125 mg po per md orders for history of hypothyroidism. TSH lab value is 6 mU/l for a normal level of 6-10. Tracheal position is mid-line. No JVD. Cough is nonproductive. Moderate amount of thick yellow secretions noted upon suctioning. Oral endotracheal tube intact 7 mm with 22 to teeth on right side. Ventilation set is HFV 500, FIO2 40%, R 10, PEEP 7, PS vent 8. ABGs reveals no imbalances at this time. No indications of labored breathing with use of accessory and abdominal muscles. Rales and crackles auscultated bilaterally. No complaints of SOB. Lasix 60mg IV BID per MD orders. No presence of subcutaneous emphysema bilaterally. Apical HR of 112 b/min. irregular with no presence of pulse deficit. Atrial flutter-fibrillation noted on ECG monitoring system at bed side. All leads for telemetry are in correct placement, with no signs of redness or irritation. BP was 117/45 by non-invasive cuff located on right upper arm, with a pulse pressure of 72. CVP monitoring via central line of 8 (6-10). Normal S1/S2 heart sounds upon auscultation at apex. Normal S1/S2 heart sounds upon auscultation at base. No murmurs or rubs auscultated throughout bilaterally. Multiple P wave is present and upright 300. Labs revealed PT of 25.7, INR of 2.2. INT placed on 02/07/2006 size 20 in left hand no redness or verbal reports of pain or any other signs of infection, dry and intact. Responds to teaching on CHF signs and symptoms, such as daily weights, feeling of SOB. Responds to teaching of diuretics (lasix) to reduce pulmonary edema. Bed-side monitor alert levels are as follows: HR hi-135 lo-65, NIBP sys hi-155 lo-95 dia hi-100 lo-50, O2 stat hi-100 lo-92. Volume for alarms are at 90%. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view.

0900

VS are as follows: HR 100, RR 15, BP vie non-invasive cuff 117/45, temp 100F, O2 98%, CVP 10. Atrial flutter and some runs of atrial fibrillation observed at bed side monitor. Output via foley is 75ml non-concentrated, yellow, clear urine for a total of 175 starting at 0600. Comfortably resting facial pain scale indicated no pain due to no grimacing, no guarding behaviors, or verbal reports indicating pain. Side rails up x4, call light within reach, bed locked in low position, HOB elevated to 30 degrees, Resting comfortably. door open with easy view.

Dratz · Jun 19, 2006

Just curious here but do you do this charting of head to toe on every patient you have and every morning? And if so, how long does it take to write all that down in the chart? And are you writing all this down as you assess your pt. or can you recall all this once you are back to the chart? Am I expected to do this detailed charting as I head into year two? I have yet to do a head to toe anything, but your detailed description has me freaking out!!.

I printed out your notes though because I think they are superb. Hope I can do as well someday.

Daytonite, BSN, RN · Jun 19, 2006

Dratz. . .you want to go with what your nursing school instructors and clinical instructors are telling you to do. The same will hold true when you get your nursing jobs. Each employer will tell you in their orientation programs what kind of charting they require of you to be doing and will give you some guidelines to follow.

moongirl · Jun 20, 2006

take a piece of paper and fold it up into your pocket.

do your assessment from HEAD TO TOE.. so you wont miss anything.

do vitals, and ask questions for aox3

then..

start with hair, ears, eyes nose mouth, the proceed downward. Take notes on that piece of paper for charting later- I am assuming that you are computer charting.

Each hosptial that I have rotated thru does charting by exception which means you dont get anywhere near as techincal as Christian's post, you only chart what is out of the normal, other than the vitals and I&O- they always get charted. If they can hear, cool.. but you dont chart it. Now if they can't hear, then it is charted. Find out what is expected of your charting and go from there

lovingtheunloved, ASN, RN · Jun 20, 2006

If there is anything in their chart such as wounds, bandages, drains etc I check them next. quote]
I don't start nursing school until August, but I've been a CNA in a SNF for three years. At the risk of sounding like a know it all, I always check new residents for any wounds and such. I say this because there have been SEVERAL times that I have come across say, a stage 4 on someone's heel or a massive bruise on someone's hip that was not documented or reported during the admitting nurse's (supposed) assessment, and upon my reporting it to the nurse, no one knew anything about it. Just to CYA.

Dratz · Jun 20, 2006

Thanks for the replies!! :specs: