Physical Assessment

[2bnurseforce1]

Hi everyone, I am having a hard time learning this physical assessment and learning everything head to toe. Does anyone have any tips on how to memorize what to do first and last in physical assessment . Any thing would be really helpful.

[CoffeemateCNA]

I just finished Assessment last week. Repetition was the only thing that really helped me, as well as practicing outside of class. All of my classmates would get together -- 1 person did an assessment on another person while the rest watched and critiqued us. Then, we took turns. I did about 25 head to toe assessments during the week of the final. Doing it over and over again helped me to remember.

My teacher also told us that in these beginning stages of learning head-to-toe assessments to make sure we follow the same pattern each time. Otherwise, we would be likely to forget portions.

There are also some links to great assessment videos in the nursing student forum -- check them out.

[zofran]

The thing is, you dont really have to memorize what to do first, second, third, etc. Just literally go from head to toe. Head first (nero) all through the systems down to their big toe. :)

In the begining, it can be helpful to bring in a sheet that you have to fiil out on each system so you don't forget. After awhile, it becomes second nature.

When I was new, I remember always forgetting to ask the pt if they were experiencing numbness or tingling.

Then I overheard a surgeon yelling at a nurse because the pt told the surgon she had been having numbness/tingling in her right side all morning. The nurse hadn't asked, and the pt didn't think about telling her. The pt ended up being dx with CVA.

You bet I never forgot to ask that question again!

P.S. Please don't forget to ask pts when their last BM was. I am so sick of finding out my pts have not had a bm in a week and nobody is doing anything about it!

[nlion87]

check out youtube for some video demonstrations

[JDougRN, BSN, RN]

Head to toe, Baby!

1. You walk into the room and observe your patient. Are they pink/breathing?ABCs

2. Introduce yourself to the patient. Do they open their eyes, talk/interact with you?As you proceed with your assesment, you will determint if their are any neuro deficits. A/O x 3

3. Go head to toe. Is there o2 in their nose? If yes, look to see how much.

4. Resp rate/rhythm. Are they SOB, or breathing easily.

5. Lung sounds. As I am positioning them to do this, I ask if they have been coughing up anything- if so, what color is it. This lets me know if I might need to pester the Doc for a sputum spec order.

6. Heart rate and regularity.If they are cardiac patients, I will ask if they have had any chest pain/pressure recently.

7. ABd assesment-BS x4, and pain, distention? Last BM?

8. GU assesment- Foley? is it secured to their leg, if not, do so, also a good time to do a quick cath care- reduce the chances of a UTI for your patient. Color/clarity of the urine. Look at it in the tube, NOT THE BAG!!!!!!

9.Thigh/leg edema, pedal pulses present and equal? Check heels for skin breakdownHomans sign possative or negative?Make sure to check patients back side as well, this can be done when you roll them to listen to lung sounds posteriorly. Remember to check their hips as well.As they move for you, you look for movement to extrematies-weakness.

7.IV site- fluid running, tubeing dated, rate/fluid correct, site benign. ID bands on the patient???? If your hospital has color coded bands (for full code vs DNR, color of the bands on the pt. correct.)

Obviously, if there are other issues, you will add them as needed, cms for casts/dressings, groin sites for cath patients, ect. This way, you won't miss anything, and your patient gets a complete basic assesment. If a problem is evident, then you go into a more detailed assesment.

[kaliRN]

You have gotten great advice here. A few things I keep in mind, think in terms of body systems while going head-to-toe. Integumentary is impt - make sure to integrate it throughout your assessment. For example, while inspecting "head," assess neuro by asking questions and interacting with pt, check for pupillary response if needed, and inspect nares and behind the ears for skin breakdown if the patient if on O2.

Be systematic and thorough. Don't take things for granted, one of the things that most defines an RN's scope of practice is their assessment skills, the physicians and patients rely on your opinion. Don't forget to talk to your patient, they are often your best guide to knowing where a more focused assessment is necessary, especially while nervously proceeding through with your instructor.

As far as "first and last" - there are very few things you have to do "in order" - the point of using a head-to-toe assessment is to stay organized and be systematic. GI is a system where order is impt - LOOK (at the shape/contour of the abdomen) LISTEN (auscultate for bowel sounds) then FEEL (palpate the abdomen). GI is also a good example of thinking about equipment. Don't forget to turn off the suction if the patient has an NGT before you listen to bowel sounds (and don't forget to turn it back on when you are done).

As with all things nursing, this will become natural, but practice and critical thinking must be employed before it does.