Please check me, quick head to toe!

[kemurphy]

Hello, I am a nursing student and I am soon being checked off doing a competent head to toe assessment in clincal. I was wondering if people could look over what my plan was and if I am correct or missing something! Thank you!!! I'm very nervous :/ Also my instructor said she really only wants to see a quick basic one to do a basic assessment not to extensive like feeling hair and checking reflexes. So I was wondering if I have everything below appropriate for a quick assesment!

I would first introduce my self ans wash my hands. Then I would tell Pt I am performing a head to toe assessment.

I start by raising the bed and asking what there name and DOB is and check Id band. Also ask where she is located and what month is it. To check orientation also could ask why are u here.

Then I would take vital signs apical pulse, BP, 02, temp, pain after

I would look at there eyes ans pupils with my pen light. After eyes I would listen to there lungs front ans back. I would look at skin on there arms andfeel for temperature and check capillary refill on nails

Then I would listen to bowel sounds and ask where there last bm was. Then I would check there legs for color temp ans edema. And check for pedial pulse.

Does this cover all basics for a quick assessment? THANK YOU!

[iwantsome]

Urinary system?

[direw0lf, BSN]

Forgot heart sounds? Lymph nodes? And provide privacy (curtain).

[negatron]

Pretty good, one thing I didn't see was the assessment for pain or complaints. Mostly pain. Checking their catheters if there are any, assess the lining and site for redness, erythema. My nursing professors had always stressed to check distal pulses bilaterally, meaning you have both of your hands on the radial at the same time to feel for symmetry, same for pedal pulse.

Nevermind: saw you included pain haha ☺️

[margin261]

I usually have pt give me a smile to check facial symmetry & stick out their tongue as well. (I missed a bad case of thrush on a non-verbal pt many years ago- it stuck with me & hasn't happened since)

Just something to consider! Good luck! Those were always nerve-wracking--just practice as much as you can, then take a deep a deep breath & go for it!

[kemurphy]

Thank you all !!!!! my teacher didn't mention anything about lymph nodes at this poimt, next semester i take a whole class just on health assesments ans im in just fundamentals so i think they arw looki gjist for basics and to put everything togetjer! I have learned to listen to heart during apical pulse. Thank u all and that's a great tip for the smile and tongue out now I won't forget that either :) also yes Thank you I'll definitely check and ask for pain

Thank u everyone for all input it helps alot

[Tex.]

[KThurmond]

I got nervous on mine and forgot to check iv sights and bandages. My advice is to review a few times before your check off. I passed but I kicked myself for it because I knew I had it:sniff: ours was our fundamentals final exam. You had a timer and performed on a mannequin in front of the whole nursing staff. Talk about nerve racking

[missmollie, ADN, BSN, RN]

Looks fine, except for the missing heart sounds. Work head to toe. Only put your stethoscope in your ears once. This is my script:

I'm going to listen to your lungs, heart, and bowel. (put on stethoscope)

Take a deep breath, good. Another. good. Another. Good. One more. Great. You can breath normally, I'm just listening to your heart beat. (move stethoscope down to belly). Now I'm listening for bowel sounds.

Keep your face neutral as you do this, and ask any questions after you've finished your assessment. Ask if they have any family history of disease. If they are confused by that (and some may be) ask "what did your grandmother or grandfather on either side die from?"

I had a patient the other day who said he had no prior medical problems, but had a heart murmur. I asked what his grandfather/grandmother died from, and he told me he didn't know, but that his father died of a heart attack at age 46. Sometimes people need permission to tell you family history, sometimes they need an explanation.

The best advice I can give you is to not act excited if you hear something that is different than expected. This is still a person who is scared and in the hospital. Keep your face neutral.

Best of luck. Assessments get easier, I promise!

[JBudd, MSN]

You've gotten a good start, and some good advice. I especially appreciate the effort you put into showing that you have thought it through before asking for help. So the next thing I would suggest is re-reading all your charting before submitting it, as instructors will be grading you on your written work as well. Documentation is critical, and nothing makes you look bad like bad charting.

"there" and "their" are not the same. If you get stuck for which is which, remember "their" has "heir" in it, ownership! There has here in it, location. Pedal, not pedial. No run on sentences, and get your spacing in. Hate to say it, but no matter how well you actually do your assessment, poor documentation detracts from it.