Quick Head to toe?

What shift do you work? I worked graves and did my assessments in pieces. The VS will give you a lot of information. If surgical, check the dressing(s) for drainage amount, color, smell, and if you need to replace or reinforce. Know the surgeon's and/or hospital preferences of this. Some docs like to do the first dressing change themselves-so just reinforce. Check the IV site and make the right bags are hanging at the proper rate. Check all drainage tubes for amount and color. And I focused on the primary system that the patient is in for. If COPD, the lungs; if stroke, the neuros. If I help the patient up to the bathroom or the BSC, check their skin for color, breakdowns,swelling, and turgor; orientation, their muscle-joint mobility, and their lungs and heart if not already done. At my hospital, it was day shift that was expected to do the main assessment. Patients don't get enough sleep in the hospital, so I tried to disturb them as little as possible. I had a nursing instructor who said you should be able to do a quick assessment in the first 30 seconds you enter the room. (She meant the life-or-death kind.) It is important to watch what needs to be watched, so you don't end up with any major surprises at the end of your shift.

These are my assessment questions, head to toe.

Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).

CP, shortness of breath, cough, palpitations?

Look at their breathing, NOTE* sometimes they will say no cough but yet you

will hear them cough (mostly post surg or pts with lung issues)

When was the last time you had a BM? N/V/C/D? (last episode)

Pain or burning with urination? (asses color of urine, or ask aid if poss)

Falls in the last year? Assistive devices? ( assess extremities, check for edema)

Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).

I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).

While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.

I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.

I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go. If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.

Kelly

1 hour ago, KellT1203 said:

These are my assessment questions, head to toe.

Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).

CP, shortness of breath, cough, palpitations?

Look at their breathing, NOTE* sometimes they will say no cough but yet you

will hear them cough (mostly post surg or pts with lung issues)

When was the last time you had a BM? N/V/C/D? (last episode)

Pain or burning with urination? (asses color of urine, or ask aid if poss)

Falls in the last year? Assistive devices? ( assess extremities, check for edema)

Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).

I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).

While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.

I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.

I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go. If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.

Kelly

Thanks Kelly, I would love to see that assessment sheet. You can email me at [email protected].

Sent!

Kelly, send it to me?

On 1/26/2019 at 1:39 PM, NurseTman said:

Thanks Kelly, I would love to see that assessment sheet. You can email me at [email protected].

I love to see what others have found useful, as it greatly helps my students too.. can you sent it to [email protected]?

Share this assessment sheet?

I occasionally listen to nursing podcasts while I am doing household tasks. I really enjoy NRSNG podcasts. They have a podcast posted on May 9, 2019 titled, "Just 5 Minutes for an Accurate Head to Toe Nursing Assessment". I found this podcast very easy to listen to and imagine myself assessing.

I came across you post regarding the medsurg, I have the exam next week, can you please send it to me. Thank you

On 1/26/2019 at 11:48 AM, KellT1203 said:

These are my assessment questions, head to toe.

Any headaches, neck aches, neck pain, stiffness? (look for glasses or hearing aids).

CP, shortness of breath, cough, palpitations?

Look at their breathing, NOTE* sometimes they will say no cough but yet you

will hear them cough (mostly post surg or pts with lung issues)

When was the last time you had a BM? N/V/C/D? (last episode)

Pain or burning with urination? (asses color of urine, or ask aid if poss)

Falls in the last year? Assistive devices? ( assess extremities, check for edema)

Then ask the patient if you can listen to their innards (I like to be funny)? (listen to heart lungs, abd).

I am constantly assessing every time I look at my patient. Looking around the room. It only takes 5 minutes, maybe more depending on the patient to complete my assessment (charting is MUCH different, but we all know how that goes).

While you are doing their skin assessment (they are walking to the bathroom or turning in bed - look at their back side) look for IV, bruising, wounds, surgical site.

I could easily be asking them while I am doing my med pass. I am not always able to get all of my information at the same time so I rely on frequent contact with the patient. If I don't have part of my assessment complete I at least start charting (when I can) and fill in the blanks later.

I do have an awesome assessment sheet I use that helps me to remember so I don't have to ask the patient again or go back to reassess. We use COWS, so I am able to make notes as I go. If you would like to check it out let me know. I would be happy to email it to you. You can make changes to it as well, tweak it to your specific needs.

Kelly

Can you email me your assessment sheet? Please

Hey Kelly,

Can you also send me that assessment sheet?

Thank you!

[email protected]

I have recently started a new job and we are looking to redo our head to toe assessment sheet.

Any chance I could get a copy?

TIA