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Discussion

Need help/advice on Head to Toe assessments

I just started med-surg clinicals and am having trouble with head to toe physical assessments. The problem is that I am not quite sure of the best way to do a head to toe full physical assessment while:

1. covering all of the body systems as I work my way down

2. going from inspection to palpation.

3. assessing the painful areas last.

4. trying to do all of the body systems thorougly (each with its own assessments).

How do I do all of this at once? Working off of my cheat sheet which is separated by body systems is taking me a long time. Is this normal?

Before med-surg clinicals we only had to do one full head to toe on one client only. Now I need to do a new one each day on a new client.

So is it best to go head to toe on each separate body system? I really have been putting my clients through a workout while taking this long time. Any helpful advice would be appreciated. Thank you.

Feeling overwhelmed,

-Blackdog

Featured Replies

Are you doing baths also?? If so this is a perfect time to do your assessment. If not when you do vitals you can tell a lot here. Just look at the person...breathing, talking, swallowing, skin color, movement ect. I use my pen light, & look at eyes, mouth, checking head, face neck while doing this...then listen to everything while looking & touching. Check pulses...looking & touching. Hand grip/leg strength...looking & touching. I do this on both sides of the body....you can see iv sites, caths, tubes, sx sites, edema, ect all while just checking out your pt. I am still very new at this so maybe someone with more experience will give you tips that might help more. I used to be very slow, but when more pt's were added I had to get faster...it is like anything the more you do it the faster & more proficient you become. I won't graduate until May...so I am in no way an expert...far from it. I just hope this will help you a little. Good luck.

  • Experts

Over the years I have pretty much learned to focus my questions and exam to the part of the body that tends to come up in the conversation. I start with the head and work my way down, but if for some reason the patient gets sidetracked talking about, let's say, his knee, then I go with that for the moment before going back to where I left off at the head or where ever. It's also good PR since it lets the patient know I'm interested in what he has to say and not just there to serve my own agenda (which I am, but I don't want him to know that). I just keep in mind that if I am at the knee that the knee is skeletal so I'm going to ask about a history of fractures, joints problems, or arthritis, how is the patient's mobility, any problems ambulating, any problems with balance and standing. When I'm in the belly I'm always thinking about the structures there and asking questions about any problems with those organs as well as listening to sounds. There's a whole lot to dwell on in the abdomen so I don't leave any organ out. In general, because I'm a lot older now, I do the vital signs, lung and bowel sounds and the physical once over and then sit down to do all the questioning. Rather than go by body system, I usually go by the organs encountered as I go head to toe. This is just the way I've learned to structure it after many years of trial and error and having to go back and ask patient's questions I ended up missing on the admission assessment because I wasn't paying close attention.

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