What does your Head to Toe really consist of?

thenightnurse456 · Feb 14, 2015

I would do what your instructor says, after all, they are the ones marking your performance, not the floor nurse. A lot of nurses cut corners to save time. Don't be that nurse.

You'll become faster with your assessments with the more experience and practice you gain.

But to answer your question, assessment priorities often depend on the floor your working.

Eg: on an orthopaedic floor your priorities in your assessment would include:

- pain assessment

-GI assessment

-vascular assessment right?

But what if your the ONLY nurse on that floor that doesn't cut corners and you take a radial pulse for the full minute and you notice that their heart rate is irregular but there is no mention in the chart of a hx of AF and you've heard nothing in report, and everyone has been charting NAD?

So you go to the doctor with YOUR kick a** assessment, he orders an EKG etc and the patient gets transferred to CCU.

Imagine if you cut corners and didn't perform the full head to toe. How long would the AF go unnoticed? What has your assessment, plan and intervention potentially prevented? PE? DVT? CVA?

I know my post won't be popular but head to toes are such a critical part of nursing. And you will get faster with time and practice.

Good luck.

Nibbles1 · Feb 14, 2015

I agree with the above poster. Now, if it's an emergency, you focus on the emergency. I don't have time to find out the primary insurance etc etc. If it's an admit, I would do a focused assessment. Asking about symptoms etc... Not doing a head to toe is taking a gamble. I had a co worker do an amazing head to toe post op. About 30 min later, patient crashed. That head to toe assessment saved that nurses rump.

anh06005, MSN, APRN, NP · Feb 14, 2015

As you get more experience you'll realize you don't have to "officially" do every bit of the assessment to actually do it. Hear me out lol.

You walk into a patient room. They give you their name and birthdate. You discuss the upcoming holiday, recent news, etc while you wash your hands. *They sure seem alert and oriented. They sit up on the side of the bed and reach over into their bedside table a foot or two away and dig around to find a mint. *ROM is pretty good. They smile at you and make some faces based on your discussion. *Facial movement symmetrical. As you're doing your assessment you look at their eyes and the pupils are equal. A quick shine of the pen light and you get to chart PERRL. Listen to heart, lungs, bowels while looking at skin along the way. Check radial and pedal pulses while, again, checking skin along the way. Ask about pain of course.

And there you have a pretty decent assessment, head to toe, in all of 5 minutes.

It'll come with time. As a student you get so focused on your one task that it's all your brain comprehends.

Mr. Murse · Feb 14, 2015

Ah, the new nurse discovering all the corners and loopholes of the real nursing world.

First off, learn to do your assessment thoroughly and correctly while you have the time and opportunity to do so. Clinicals are all about learning the right way to do things, and the reasons for doing them. Once you get those foundations built, then you will be able to recognize where you can safely cut corners and where you can save time.

What I mean by safely cut corners are things like what you can gather simply by walking in a room and conversing with the patient, because your assessment begins as soon as you set eyes on your patient (or sometimes when you hear them outside the door). By their speech and expressions and reactions and body movements alone you can cover a significant amount of your assessment. Then multitask. If you're checking pedal pulses, you should simultaneously be assessing skin integrity and edema in their legs. If you're listening to bowel and lung sounds, you're also assessing characteristics of their abdomen and breathing. While you're talking to them or their family, you're also looking around the room, checking IV settings, drains, etc.

Unless I get hung up on something I can usually knock out a pretty thorough head to toe shift assessment in 5 minutes or so.

psu_213, BSN, RN · Feb 14, 2015

On most non-ICU/non-stepdown units, a nurse will be doing a focused assessment (other than the initial assessment for a newly admitted pt., which should be head-to-toe). For example, a pt. has been on the unit for 3 days, getting ABX for PNA. I would focus on breathing, lung sounds, cough, sputum (presence of and nature of). By talking with the pt you will have a pretty good idea of A&O. Unless they have a known issue with it, I'm not going to assess pedal pulses, grip strength, pupil reactivity, etc. If there is any indication that I need to assess them, I will; however, in my focused assessment, I'm going to stick with the pt's reason for being in the hospital.

~PedsRN~, BSN, RN · Feb 14, 2015

Yes, in the real world your assessment is going to be focused on what's going on with your patient.

RNperdiem, RN · Feb 15, 2015

In ICU it starts with assessing level of consciousness, level of orientation, pupils, lung sounds, heart sounds bowel sounds, ability to move all four extremites and with how much stength, a look at the condition of the lines and a pain assessment is a basic assessment.

Beyond that it depends on what you are looking out for. For a neuro patient, I usually add in checking cough, gag and corneals. For a trauma patient, I do neurovascular checks on affected limbs to assess circulation, color and sensation. For a ventilated patient, checking pressures and volumes on the vent plus level of sedation is included.

Every patient gets the basics, and beyond the basics in specific circumstances. You customize the assessment to the patient.

danielle2000, MSN, RN · Feb 15, 2015

I can see for an admission doing a head to toe assessment. In our FNP we have to a full head to toe by heart no notes with in an hour. Surprisingly, you will do it. There are so many resources on you tube on how to do various head to toe assessments especially when you are incorporating the cranial nerves!!!!! Just practice and write out a script and you will never go wrong. :-)

danielle2000, MSN, RN · Feb 15, 2015

@anh06005 that is what I am talking about. You are a sharp NP :cool:

anh06005, MSN, APRN, NP · Feb 15, 2015

@anh06005 that is what I am talking about. You are a sharp NP

Lol. I'm still working on the NP assessment part. Only 3 weeks into my first job!

LadyFree28, BSN, LPN, RN · Feb 15, 2015

Ah, the new nurse discovering all the corners and loopholes of the real nursing world.
First off, learn to do your assessment thoroughly and correctly while you have the time and opportunity to do so. Clinicals are all about learning the right way to do things, and the reasons for doing them. Once you get those foundations built, then you will be able to recognize where you can safely cut corners and where you can save time.
What I mean by safely cut corners are things like what you can gather simply by walking in a room and conversing with the patient, because your assessment begins as soon as you set eyes on your patient (or sometimes when you hear them outside the door). By their speech and expressions and reactions and body movements alone you can cover a significant amount of your assessment. Then multitask. If you're checking pedal pulses, you should simultaneously be assessing skin integrity and edema in their legs. If you're listening to bowel and lung sounds, you're also assessing characteristics of their abdomen and breathing. While you're talking to them or their family, you're also looking around the room, checking IV settings, drains, etc.
Unless I get hung up on something I can usually knock out a pretty thorough head to toe shift assessment in 5 minutes or so.

^This.

I can knock out an assessment 2-5 minutes tops. :yes:

I work Peds, and STILL can knock out an assessment at least in 5 minutes, even if I have to do a

focused assessment (ER), I still do a

quick assessment on other systems.