Quick Head to Toe Assessment

[ProbowlerRN]

hello I am a new grad who just started on the M/S floor. I feel that I am too detailed with my assessments and don't have enough time for the other things. Can someone give me an example of how they do their head to toe at bed side in less than 5 minutes that covers all bases?

thank you so much

[turnforthenurse, MSN, NP]

Orientation (also seeing if they acknowledge you when you walk into the room), pupils, heart/lung/bowel sounds, ask about any nausea/vomiting/diarrhea, palpate the abdomen, look at lower extremities for any swelling and check pedal pulses. Ask about pain. Then I tailor it to each patient. If a patient is there for something neuro-related and they are on neuro checks, I make sure to check hand grasps and pedal pushes, ask them to smile/stick their tongue out, perform the NIHSS if they are there for a CVA (in addition to assessing orientation, speech, pupils, asking about numbness or tingling). If they have an NG or PEG then of course I will check placement and check residuals. If the patient had a cardiac cath, then I will need to assess the cath site for hematoma formation, check the pedal pulses and ask about any numbness or tingling or any pain.

You will eventually become faster at completing your assessments but also with expertise. As a new grad you're learning how to manage your time among other things because there is a steep learning curve when you first start.

[FurBabyMom, MSN, RN]

I agree with the previous response regarding general assessment, it's fairly comprehensive. I'm particular, so I also checked any lines or tubing - if a patient had O2 ordered I checked that it was set appropriately (and that it was on and/or provided teaching re: oxygen use for reluctant patients), I checked that my IV lines were running as ordered (maintenance fluids at correct rate, any other special drips at the correct rate and programmed accordingly), if IVs were locked I flushed them (we assessed/documented IVs and other lines with our system assessment). I checked NGs, PEGs for placement and residual. I also looked at my tubes/drains - if my patient had a hemovac or a foley I checked to see what the drainage looked like and if it needed emptied I did so. I also checked tele if applicable (is the monitor reading at the desk, do batteries need replaced, are the leads all on).

I handled my nights neuro/med surg tele, by getting report and doing introductions first. You gain so much information during introductions. You get to look at your patients and determine if they are in any kind of distress and decide who to see next. You can get a good idea of your patient's status just by looking at them (are they alert to people entering the room, what is their color like, what is their respiratory status (can they move air and talk at the same time? Or are they unable to catch their breath?). Many times our report time was crazy, when I had to wait to get report on patients from other nurses I would assess the ones I'd already gotten report on (it's what I had to do for time management).

I usually talked to my patients while I was assessing them. It takes practice, but I can ask them about orientation, numbness, tingling, etc - while listening to breath sounds, heart sounds and bowel sounds. If I hear something not normal or not baseline for that patient, I would spend more time verifying (ex hearing wheezes in a patient might warrant me to listen in multiple places or a little longer than normal, esp if wheezing was not normal for the patient). Working primarily neuro, we always had to check grasps, and pedal push/pull back, extremity pulses, color and appearance of extremities. I always looked at facial symmetry (you can get a good idea watching while they talk to you) and ALWAYS checked pupil reactions.

My advice would be to look at how your facility documents. Both jobs I had as a med surg RN charted by exception. Learn what "WNL" or "WDL" means for a specific body system, and that gives you a good idea what you need to assess for each system. It really does come faster with time!

I would agree, it is very difficult to learn to manage your time as a new grad but you will get there! I promise! Sooner than you would imagine too! Ask your preceptor how they do their assessments and/or watch them and ask questions. See how they group things. It helped me so much watching my preceptors. When you get a little more comfortable, ask you preceptor to help you - ask them to watch how you handle assessments and other time management skills.

[HyperSaurus, RN, BSN]

Introduction (gives you a tid/bit for orientation, as for pain at same time), heart/lung/bowel sounds (good time to check incentive spirometry use, cough, flatus, bowel movements prn), palpate abd, neuro check (grasps, push/pull, smile, pupils) if neuro diagnosis, radial/dorsalis pedis/posterior pedis pulses (edema check at same time), then tailor to pt needs. Skin as needed, IV sites (although that is the area I am most likely to forget), any additional lines (foleys, ng, g-tube, peg-tube, jp drains, chest tubes), and dressings. I have relatively recently started charting 'on the fly', as that seems to help me get out on time. Essentially, I chart on relevant issues between every assessment, and then chart on other stuff later when I have time (I have to chart on 8-12 pts a night)

[SaoirseRN]

I agree with what the other posters have said. Much can be accomplished while talking to the patient. While I'm taking their vitals, I ask about pain or discomfort and assess their orientation. Usually at the same time I can check lines, oxygen, and IV rates.

Then do the rest, tailored to each patient, spending more time on the pertinent assessments and less on the general ones. The one thing I don't do first thing is a full skin assessment. For the ones who need it, I can assess that when I'm helping them bathe.