Need Advice on Head to Toe Assessments

[blackdog]

Hello. I am an LPN student just starting hospital (med-surg) clinicals after completing nursing home clinicals. In the nursing home we only needed to do 1 complete head to toe assessment of all the body systems on 1 client. Now in the hospital we need to do one per day and I am at a bit of a loss. It's probably a stupid question, but here goes: When doing a head to toe assessment on all of the different body systems do I try to assess all of the body systems as I work my way down so that I only work from head to toe once? Or do I basically do a head to toe for each body system (as required for that body system)? I am trying to assimilate all of the body system assessments into one large head to toe assessment and also do the least invasive (palpation) techniques last and basically I am just getting mixed up. The 2 patients I have had so far have been patient with me but I can't keep doing it in this mixed up way. Thanks in advance.

-Blackdog

[cherokeesummer]

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.

I have learned that it differs from each teacher! Some of my teachers want to know every detail of what we do in the form of nursing notes, other teachers want only to know the basic essentials and figure everything else is on the flow sheet and does not need to be written. The majority of our teachers prefer quick concise notes like:

0700 Assess A & O x 3. Sitting in bed watching TV. Denies needs. Family member at bedside. IV running D5W patent, no edema, redness or pain.

Etc.

I have always wanted to say like vitals ..... pain..... but my teachers are now telling us no need b/c it is in the flow chart. So make sure you check with your isntructor to see what they prefer. :):)

I agree those notes were good!

[NICU_nurse2b]

This thread has been extremely helpful for me. I am having trouble with assessments and charting and after reading this thread it is starting to make make sense to me. I am determined to do a much better job on Monday!:thankya:

[beachbum3]

I start with vitals. You can be assessing the cognitive stuff just thru conversation. When I am finished checking the radial pulse I check capillary refills at the fingernails, you could do handgrips then too.

Then start at the head. I do ear occlusion, three word memory test, pupil reaction.

Palpate Carotid pulses.

Palpate chest, skin turgor check on chest

Listen to apical pulse

Listen for lung sounds on the front

listen for bowel sounds

palpate abdomen

-ask about urinary/elimination problems as I palpate, also daily food and fluid intake

back side breath sounds

pedal pulses

check for edema around ankles

capillary refill on toe nails

strength testing of extremeties

coordination testing

dull/sharp test

ROJM testing

If they are mobile you can assess gait when they are getting in and out of bed to go to the bathroom etc. Otherwise I'd have them stand if they are able.

Also all the while you can be assessing the skin, and finding out things through conversation.

When I was unsure of myself with this I made myself a little cheat sheet. I typically just write down the vitals- I can remember everything else. If there are alot of abnormal things, I might make notes. My head to toe assessment usually takes about 20 minutes- tops. We have 2 pts and have to do an assessment first thing in the am, and then again around lunch time. Don't worry- you'll get comfortable with it!:wink2:

[littlebit2008]

I am a nursing student and have never done a head to toe assessment, I found all the advice very helpful. My question is this, do you always doe the same things for every assessment that you do and do you do them basically in the same order. Also I noticed that there are several different ways that people do them. Is there anything specific that you can tell me about doing my first one? thanks to all

[Daytonite, BSN, RN]

i am a nursing student and have never done a head to toe assessment, i found all the advice very helpful. my question is this, do you always doe the same things for every assessment that you do and do you do them basically in the same order. also i noticed that there are several different ways that people do them. is there anything specific that you can tell me about doing my first one? thanks to all

when you are new at this you start out doing assessments the same way in the same order every time. do what you feel comfortable with. as you begin to get experience and get comfortable with assessing, you start to develop a style of your own. in fact, your style will evolve over many years.

there are a number of weblinks to head-to-toe assessments on this sticky: https://allnurses.com/forums/f205/health-assessment-resources-techniques-forms-145091.html. it doesn't matter which you use. pick one you feel comfortable with.

[avahnel, ASN, RN]

I have a question. When you are doing an assessment on your patient in the real world, how do you go about doing a full skin check? I am a first year student, and am getting over the privacy issue, and realizig that as nurses, we are in intimate spaces with all of our patients. When I have only one patient, now I can do a good skin assessment when I give my patient thier bath. But if they can do thier own bath what do you do? Just say-I have to check your skin? I was taking care of a patient two weeks ago, and the nurse who did the physical assessment missed a stage 2 ulcer under the pts L breast because he said he was "trying to be a gentleman". I found it and put barrier cream on it, showed it to him and he talked to the Dr to see if nystatin powder should be ordered. I don't want to miss things like that. Is the privacy thing just something I have to get over?

[quiet_one]

This is a cheat sheet you can use when your in a pts. room, all you have to do is circle or maybe write in some info, it is not all inclusive but will give you a really good start on covering all the systems. I also would suggest getting a book that is just about nursing assessments, I have mosby's 10min assessment and I used it everyday in first and second semester and now that i'm in third I think I have the whole book memorized :)

Assessment Worksheet patient initials: date:

Vital signs

Temp (ax, tym, o, rectal):___________________________________

B/P: _____________________

P:_______________________(weak, bounding, full) (regular or irregular)

R:______________________(shallow, full, deep) (regular or irregular) (labored or nonlabored)

LOC

AAOx3 (yes, no)__________________________

O2 @_______L/(N.C., mask)

PERRLA (yes, no)______________________________

Skin (as it relates to circulation or oxygenation, not about intact or lesions)

(wet, dry, or clammy)

Color (pink, pale, cyanotic)

Capillary refill

Turgor (with or without tenting)

Muscous membranes (moist, dry) (cracking, no cracking) (pink, cyanotic)

Respirations

(even or irregular) (labored or non-labored) (clear, rales, rhonchi, rubs, wheezes) *if so are these inspiratory or expiratory? Anterior, posterior or both? Upper or lower lobes?*

Cough (yes, no)

Sputum produced (yes, no) if so describe___________________

Are the breath sounds equal bilaterally (yes, no)

Heart

(regular/irregular)

Murmors (yes, no)

(strong, weak)

Abdomen

(round, obese, grossly obese, sunken, emaciated, soft, firm ,distended, no-distended)

Active bowel sounds x4 (active, hypoactive, hyperactive, absent)

Last bowel movement___________________---

Describe__________________________

Laxatives (yes, no)

Feeding tube (yes, no) if so what region is it located in and what type of nutrition is being given__________________

Rate_________________ Site appearance (redness, lesions, drainage) _______________________________

Voids (with or without difficulty)

(stress incontinence, incontinent, wears diapers, uses pad)

F/C patent and draining _____________________color of urine________________approx amount_____________

MAE with FROM _____________________

Grasps (equal, not equal)

Weakness______---

Paralysis__________

Pedal pulses (palpated, unable to palpate)

Edema pitting (2+,3+, 4+)

If unable to palpate describe temperature and capillary refill of feet as well as color or any lesions or redden areas?__________________________________________________________________________________________________________________________________________________Skin Intact (Yes,No) ___________________________________________

IV therapy site_______________________describe site_________________________________--

Infusing______________________@rate of__________________

Where is the client (bed, chair)

Side rails 1-4 ____

Call light, phone , water within reach? ______________

Does client voice any c/o?________________________________

How patient feels: __________________________________________________________________________________________________________________________________________________________

*pain 1 2 3 4 5 6 7 8 9 10

Location:

Duration:

Characteristics:

Quality:

Religion:

History of Smoking (Yes, No)_____________________

Alcohol Abuse? (Yes, No)__________________________