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Nurses   (3,257 Views 19 Comments)
by LouisVRN LouisVRN (Member)

9,106 Visitors; 672 Posts

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do a complete head to toe assessment? What are things you ALWAYS assess? I've been told by patients that I'm the first to listen to them with a stethoscope. How do you document when you did not do a complete assessment on an area (ex. deferring a reproductive exam on an appy pt)?

I have a list of always assess things - cardiac/lung/bowel sounds, radial/pedal/post tibial pulses, sensation, basic neuro status, access device, pain. Then focus on whatever the problem is and assess that.

just curious on everyone's practices.

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iNurseUK has 20 years experience and works as a Sister of Oncology Ward.

1 Like; 6,205 Visitors; 348 Posts

Depends upon what ails the patient and what complications are likely to arise from the admission diagnosis.

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9,106 Visitors; 672 Posts

Depends upon what ails the patient and what complications are likely to arise from the admission diagnosis.

I mean just more in general though - granted any assessment will be tailored to the patient. But in a non-emergent impatient situation anything that you wouldn't leave out or anything that is regularly left out?

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Neuro Guy NP has 7 years experience as a DNP, PhD, APRN and works as a Neurocritical Care NP.

17 Likes; 6,707 Visitors; 183 Posts

To me, a full head to toe should be done when the patient is first admitted to the hospital, perhaps before discharge or so. Also, I might do a full head to upon admission to the floor when the patient comes from elsewhere or I might do only an assessment of the body system experiencing problems and directly related organ systems, etc. For example, for diabetics I would not only examine endocrine function, etc. but also assess the CV system and look at renal related lab reports. For the CHF pt, I would obviously examine the CV system but also respiratory and integumentary (for edema, etc.). I wouldn't place musculoskeletal system as a very high priority with CHF.

So basically, to sum up my longwinded answer, often times a focused assessment is often sufficient, but of course a complete head to toe should be done when your nursing judgment indicates something is up and so forth.

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Brea LPN has 5 years experience and works as a LPN.

3,700 Visitors; 143 Posts

I know this doesn't answer your question, but I wouldn't leave anything out of a head to toe assessment. I know nurses do it to save time, but what if the one thing you leave out causes serious injury to the patient costing you much more time in the long run. Such as not listening to bowel sounds causing a perforated colon, or not assessing pedal pulses causing a DVT to dislodge. I would rather catch inactive bowel sounds or a DVT early, not when my patient is being rushed into surgery.

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9,106 Visitors; 672 Posts

I know this doesn't answer your question, but I wouldn't leave anything out of a head to toe assessment. I know nurses do it to save time, but what if the one thing you leave out causes serious injury to the patient costing you much more time in the long run. Such as not listening to bowel sounds causing a perforated colon, or not assessing pedal pulses causing a DVT to dislodge. I would rather catch inactive bowel sounds or a DVT early, not when my patient is being rushed into surgery.

For the most part I agree, however I routinely defer reproductive exams unless the patient is admitted for that reason as I feel it would often times make the patient uncomfortable but I wasn't sure if this was standard practice.

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mrsshifflette09 has 3 years experience and works as a Neurosciences Stepdown Unit.

2,583 Visitors; 86 Posts

On the floor that I work on, we do a full head to toe Neuro assessment every 2 or 4 hours, depending on the stability of the patient. We do one full head to toe assessment each shift. I don't always feel that it is necessary to do a full head to toe assessment on every patient, but I just do it anyway. It takes less than 15 minutes and I only have 3-4 patients at a time so its not too bad.

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TheCommuter has 10 years experience as a BSN, RN and works as a CRRN, now a case management RN.

21 Likes; 1 Follower; 228 Articles; 315,312 Visitors; 27,607 Posts

I work in an acute rehab hospital and have an average of 7 to 12 patients on night shift. I do a head-to-toe on all new admits. Otherwise, I'll do a quick focused assessment.

When I was a hospital patient back in 2008, none of my nurses dropped a stethoscope on me at any time. A couple of them never looked at my right groin, which was the site where the doctor had cut me to insert the catheter into my femoral artery. The only time a full set of vitals had been done was during the admission assessment. However, all of my nurses appeared to be busting their butts and spread too thin to have the time for any deeper levels of assessment.

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5 Likes; 3 Followers; 17 Articles; 65,646 Visitors; 5,259 Posts

I work OB/nursery.

For an adult:

Listen to heart/lungs/bowel

Assess breasts/nipples

Assess bowel/bladder function (this includes checking for hemorrhoids)

Check incision/perineum for sx infection or dehiscence

Fundal height and lochia

Assess pedal pulses, and check extremities for edema and/or sx of DVT

If she is still pregnant, I check fetal heart tones

Newborns are a different story altogether....

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kellyc034 works as a Registered Nurse.

3,860 Visitors; 117 Posts

I work in cardiac step down, and I assess lung sounds, abdominal sounds, pedal pulses, IV access, basic skin for edema- ecchymosis, and general mentation. If the pt came in with bed sores, or has been immobile for a while I take a look at their backside. If they are post op I check out the incisions- chest tube sites, etc. I chart full in depth assessments for my first one on all patients, and for my second assessment I address really only what was abnormal the first go round.

Kelly

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Brea LPN has 5 years experience and works as a LPN.

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For the most part I agree, however I routinely defer reproductive exams unless the patient is admitted for that reason as I feel it would often times make the patient uncomfortable but I wasn't sure if this was standard practice.

I could understand that, but you could assess the perineal area while giving a bath, helping a patient to the bathroom, or changing an incontinent patient. But this may not be possible with a completely independent patient.

So a quick question the nurses that don't do a full head to toe assessment:are you charting the things you are not checking as normal? Such as with charting by exception?

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9,106 Visitors; 672 Posts

I could understand that, but you could assess the perineal area while giving a bath, helping a patient to the bathroom, or changing an incontinent patient. But this may not be possible with a completely independent patient.

So a quick question the nurses that don't do a full head to toe assessment:are you charting the things you are not checking as normal? Such as with charting by exception?

The patients I am talking about are primarily completely independent admitted for 23 hours obs s/p appy/chole. i usually will just comment "pt does not state any complaints/concerns" I always make sure to ask my pts if they have any concerns/ complaints that I have not addressed. I know a lot of people just chart as WNL but I don't feel comfortable doing that unless I've seen it myself.

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