I am giving a presentation this week and would love to add some comments from US nurses and nurses from overseas who are now working in the US.
How important is it to complete a head to toe assessment Q4 hrs - why do it, why not and whats your average time to complete. ICU nurses - how often do you complete them in the Unit?
History behind my question. I am a UK nurse who worked for more than 10 years in the US, and now that I am back in the UK, find it hard to understand why we do not do them here. Hence I am writing a refelctive essay on physical assessment, as well as giving a presentation.
i have to agree with the fact that an actual complete head to toe is not something that needs to be done every 4 hours, unless they are critical.. once a shift is fine in most aspects... i work in the ER and i will be honest... i don't do a complete head to toe assessment very often at all.. i do more focused assessments depending on their chief complaint... unless it is a trauma of course.. thats a different story..
honestly though... as was stated above.. not many ppl actually know how to really do a complete assessment which includes cranial nerves and neuro as well as reflexes.... not just general apperance, lung sounds, heart sounds, abd apperance and bowel sounds, extremities, cap refill, blah blah blah..
i usually spend less than 5 minutes assessing a pt. initially...
hx... signs and symptoms... onset... past med hx... blah blah... vitals 5 mins.
I assessing cranial nerves isn't part of a general head to toe assessment. That would be a more focused assessment on a patient with a head injury or other neurological disorder. When I worked in the ER, I did head to toes on all my "monitored" patients. If you were in for a broken toe, you got you toe and pain assessed. If your were a cardiac, trauma or stroke patient, I always did a head to toe.
Specializes in ER/Tele, Med-Surg, Faculty, Urgent Care.
by definition, a complete head to toe includes all the cranial nerves, reflexes, light & deep belly palpations etc etc but that is usually not done except in a clinic setting when someone needs a physical and them boy have i seen plenty of short cuts. ( 5 min sports physicals!!)
it sound like most of the postings everyone knows when you need to go into more detail in one area or another depending on the patient, but these are technically not complete head to toe assessments but partial or focused assessment. as a former er & med-surg tele nurse with 30+ years experience, i rarely did complete head to toes, they take at least 45 minutes to do per patient. but we all know the value of doing a quick basic (loc, pupils lungs heart, pedal edema, last poop,pee etc etc 5 min assessment even if we come back later and do it again more thoroghly. the times i have been burned because i got an admit at start of shift or we had a code at start of shift then 1-2 hours later found patients in resp distress , well it happens more then i like. sounds like we have some terrific clinicians posting here. keep up the great assessments!!!
nghtfltguy, BSN, RN
314 Posts
i have to agree with the fact that an actual complete head to toe is not something that needs to be done every 4 hours, unless they are critical.. once a shift is fine in most aspects... i work in the ER and i will be honest... i don't do a complete head to toe assessment very often at all.. i do more focused assessments depending on their chief complaint... unless it is a trauma of course.. thats a different story..
honestly though... as was stated above.. not many ppl actually know how to really do a complete assessment which includes cranial nerves and neuro as well as reflexes.... not just general apperance, lung sounds, heart sounds, abd apperance and bowel sounds, extremities, cap refill, blah blah blah..
i usually spend less than 5 minutes assessing a pt. initially...
hx... signs and symptoms... onset... past med hx... blah blah... vitals 5 mins.
i then go focused from there~~