General Bedside Assessment (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 Hello. I'm Samantha Rhea.

    00:03 Today I'm going to show you how to do a head to toe assessment in about 5 to 10 minutes.

    00:08 I like to call this a clinical head to toe.

    00:11 Now, refer back to your health assessment class.

    00:14 Remember all those details that you had to remember about assessment, such as cranial nerves or reflexes? Now, I'm not saying those aren't important, but just remember, those are tools in your tool belt when you need to do an advanced assessment.

    00:29 Now, we also have a great lecturio course, with a detailed physical assessment that we have in our curriculum for you to refer to if needed.

    00:38 Now, when I'm doing and/or I'm demonstrating my head to toe assessment for you, we're going to have a forum to show you what electronic health record might look like and how you document details of the assessment.

    00:50 So again today, I'm going to show you about a 5 to 10 minute head to toe assessment that you're going to see much like nurses do at the bedside.

    01:03 Hi, can I come in? Yes.

    01:05 All right. Great.

    01:06 I'm Samantha. I'm going to be your nurse today.

    01:09 Do you mind if I take a look at your wristband? All right. Great.

    01:12 Can you go ahead and tell me your name and date of birth? Brandon Smith.

    01:15 March 7th. 1996.

    01:17 Perfect.

    01:17 Can you tell me where you're at right now? Hospital. All right.

    01:22 Can you tell me what month you're in right now? January? Yes, very good. Okay, great.

    01:26 So today I'm going to do a quick head to toe assessment.

    01:29 It should really only take about 5 to 10 minutes.

    01:31 Is that okay if I go ahead and proceed with you? Yes.

    01:34 Okay, great.

    01:35 So tell me, what actually brought you into the hospital? High blood sugar. High blood sugar. Okay.

    01:40 Is there anything of concern that you would like me to address during this shift while I have you under my care? No, I feel fine now. Okay.

    01:46 So no pain or anything like that? No.

    01:49 Okay, great.

    01:50 So when I do my head to toe assessment, I'll kind of walk you through and give you some prompts.

    01:54 So if you have any concerns, please let me know.

    01:56 All right.

    01:57 Okay, great. So, let me go ahead and start with your head.

    01:59 If you would, I'm going to take a look at the back of your head real quick.

    02:02 Okay, great. All right. Thank you.

    02:05 All right.

    02:06 So I'm going to go ahead and take my penlight.

    02:07 So this will be a little bright.

    02:09 I'm going to take a look at your eyes as well.

    02:12 All right.

    02:12 Look right here on me. Okay, great.

    02:15 Good.

    02:16 And I'm going to do it on the other side, too.

    02:18 Great. Okay.

    02:20 So are you having any vision problems? Blurry vision, that's weird for you.

    02:24 Any eye pain? No.

    02:25 Okay, great.

    02:26 So, I'm going to take a look inside your mouth as well.

    02:28 Say 'ahh' for me. All right. Great.

    02:31 So what I'm going to do now, I'd like to assess your range of motion with your neck and your shoulders.

    02:37 So if you would and you can just say straight as you are, I would like you to move your head from right to left.

    02:44 Perfect.

    02:45 And now up and down for me.

    02:48 Great.

    02:49 So now I want you to shrug your shoulders, like, all the way up to your ears for me. Very nice.

    02:55 Perfect.

    02:56 Now, do you have any discomfort, pain or anything with your neck, shoulders, any of that? No. Okay, great.

    03:02 All right, so now I'm going to test your strength on your arms.

    03:04 Can you give me your arms and raise them up for me? Good.

    03:07 So I want you to squeeze my fingers. Don't be shy.

    03:09 Nice. Hard squeeze. Okay.

    03:11 Squeeze, squeeze, squeeze.

    03:12 Very good. All right. You can relax your arms.

    03:14 So now I'm going to just take your fingertips, and I'm going to push just to check your circulation.

    03:21 All right.

    03:21 Very nice.

    03:22 Good.

    03:22 All right, you relax your arms and I'll check your pulses real quick.

    03:25 You can relax those.

    03:32 Okay, good.

    03:33 So now I'm going to go ahead and take a listen to your chest.

    03:36 So I'm going to take my stethoscope.

    03:38 I'm going to listen to your lungs and your heart and the back of your lungs as well, back side.

    03:43 And when I do that, I'm going to have to get under your gown because my stethoscope, will be able to hear much better if that's okay with you.

    03:49 Okay. All right.

    03:52 All right.

    03:52 So I'm just going with the side here.

    03:59 Sorry if I have cold hands here.

    04:02 And you just breathe normally.

    04:10 Good.

    04:12 Good.

    04:17 Good.

    04:18 Okay.

    04:19 If you'll sit up, I'm going to take a listen in the backside.

    04:23 Good.

    04:41 All right, go ahead and relax.

    04:42 Brandon your lungs sound really good.

    04:44 Are you have any trouble breathing, shortness of breath? Any issues with that lately? No. Okay.

    04:49 What about now? No. No? Okay.

    04:51 I'm going to listen to your heart, so let me get back on your gown again from the side.

    04:54 And you can just relax.

    05:08 Okay, good.

    05:09 Your heart sounds nice and strong and regular.

    05:11 So now I need to take a look at your abdomen.

    05:13 So is that okay if I take a look and just make sure your skin and everything looks good and if there's any sores or wounds that I need to address? Okay, great. Thank you so much.

    05:23 Okay, good.

    05:25 Okay.

    05:25 I don't see any major bruising or scars. Good.

    05:28 So now I'm going to take a listen to you, and I'm going to do the same thing with my stethoscope and listen to that, okay? All right, great.

    05:35 Start in your right side here.

    05:48 Okay, good.

    05:49 Thank you.

    05:50 All right.

    05:52 So I hear good bowel sounds.

    05:53 Now, let me ask you, how's your appetite? Has that been okay? No recent major weight loss that you're concerned about? No. Okay.

    06:01 What about your bowel patterns? Like any diarrhea or issues there? No. Okay.

    06:07 When was your last bowel movement? Yesterday. Yesterday.

    06:09 Okay, great.

    06:10 So what about urination? Like, are you able to urinate okay, no issue starting stream, burning, any weird drainage, anything we need to address? No. Okay, great.

    06:22 So this would be a good time, actually, with your patient, and just look, as appropriate to assess the patient's genitals or your buttocks.

    06:30 Some patients we want to make sure there's no excoriation or any wounds or anything we need to address.

    06:35 But now I'm going to go ahead and move on to his legs.

    06:38 Okay.

    06:38 Brandon So let me go ahead and move on your legs.

    06:40 And if that's okay, I'm going to pull back the covers, and I'm just looking for any swelling.

    06:46 I'm just going to push on them.

    06:49 Make sure.

    06:50 Okay. Good.

    06:52 All right.

    06:54 Very good.

    06:54 Okay, I'll pull these down so you won't get so cold.

    07:00 All right, good.

    07:02 Okay.

    07:03 So now I'm going to assess your strength.

    07:04 What I'd like you to do is take this foot and touch my hand and keep it up there on me. I'm going to count to 5 okay? So, I'm going to assess your strength.

    07:11 So lift that for me. Good.

    07:13 So on the count of 1, 2, 3, 4, 5.

    07:17 Very nice. All right, we're going to do it with the other one as well.

    07:20 So, 1, 2, 3, 4, 5.

    07:24 Very nice.

    07:25 So now I want you to push like you're pushing on the gas.

    07:27 Push hard.

    07:28 Very good.

    07:29 Okay.

    07:30 So now I want to pull towards your face.

    07:32 Very nice. Okay.

    07:34 And I'm just going to feel the bottom of your heels and make sure we don't have anything breaking down here.

    07:39 Very good.

    07:40 Okay.

    07:40 So, I'm going to just check your circulation in your toenails.

    07:46 Looks good.

    07:49 Okay, good.

    07:50 All right.

    07:50 Let me assess your pulses.

    07:56 Very nice.

    08:01 Okay, great.

    08:03 So that finishes up our assessment Brandon, thank you! I appreciate it.

    08:06 Is there anything else I can do for you? Before I step out? No. Okay.

    08:11 All right.

    08:11 So when we finish up our head to toe assessment, there's a couple of things to remember.

    08:15 You know, when we walked into the room, you can see that Brandon's already setting up.

    08:19 He's alert.

    08:20 He's responsive. He's not in any distress.

    08:23 Also, at that time would be a good time to check for any drains or tubes and make sure you assess those.

    08:29 And, of course, before you leave the room, make sure Brandon's got his bed all the way to the lowest position and the side rails are up times two as well.

    08:36 Thanks for watching.

    08:41 We've just done a physical assessment on our client, Brandon.

    08:45 I'd like to show you an example of how we might chart that or what a charting might look like on the patient.

    08:52 So we've got a male client with the age of about approximately 30 years old.

    08:56 Now on general appearance, his overall body build is appropriate and within normal limits for a height, a six foot and weight of 190 pounds.

    09:07 Now, when we are doing assessment on our client, Brandon, his facial expression was calm.

    09:13 He was cooperative and willing to answer questions.

    09:17 Now, when we're taking a look at Brandon's neurological status, let's take a look at his level of consciousness.

    09:23 So he was alert, awake and responsive to questions.

    09:27 And Brandon is oriented times 4, so he was oriented and knew his name, his date of birth, where he was and also his chief complaint.

    09:38 He was also responsive to voice.

    09:41 So we're overall looking at Brandon's head.

    09:44 He did not complain of a headache so that was great.

    09:48 Also, when we took a look in his ears, we didn't see any drainage, any scabs, any issues there, and it was within normal limits.

    09:55 He also does not use any assistive devices for his hearing.

    10:00 Now moving down to Brandon's mouth: His teeth were healthy.

    10:04 They were intact.

    10:05 Also his mucous membranes were moist and intact as well.

    10:09 And general appearance for his skin on his head was pink and intact.

    10:15 When we focus in on Brandon's eyes, he had good vision and good visual eyesight.

    10:20 We take a closer look at his pupils.

    10:23 They were equal, round and reacted to light.

    10:26 And we had a consensual response, which is positive.

    10:30 Brandon's pupil size before the penlight light was 4 millimeters and after the light we documented at 2 millimeters.

    10:39 Now, moving from Brandon's head to his neck, we check to make sure we don't see any jugular vein distension because we do not want to see that in a healthy patient.

    10:48 And this was not visible.

    10:51 Now, after we've assessed Brandon's neck, we're going to move down to the chest.

    10:55 So we assessed Brandon's heart rhythm.

    10:58 It was regular and there were strong sounds of S1 and S2.

    11:03 Now, when we're documenting respirations for Brandon.

    11:06 There were regular, even, unlabored, and symmetrical.

    11:11 Now, on auscultation when we listen to Brandon's lungs, they were clear in all upper and lower lobes anteriorly and posteriorly, and Brandon didn't have any cough.

    11:23 Now, when we moved down to Brandon's arms on assessment, his hand grips were equal and strong and we rate that at a five plus.

    11:32 We were also able to check brain and circulation with his radial pulses, and those were both palpable on the left and right radial pulse.

    11:41 And checking capillary refill in both the right and left arm extremity.

    11:46 It was normal.

    11:47 And overall, Brandon's arms, the skin was intact, the color was normal.

    11:53 We didn't see any tinting that is a sign of dehydration.

    11:57 His skin was warm and it was dry.

    12:00 Now, on Brandon's arms that we had, as you just heard, good circulation.

    12:04 We saw pulses, a normal cap refill.

    12:08 And he was able to feel when I was assessing his pulse and the temperature was normal.

    12:13 Brandon was also able to move around his arms as active range of motion, and this was within normal limits.

    12:21 Now moving from chest down to the abdomen.

    12:23 Brandon's abdomen was soft, flat and not distended.

    12:28 Also, Brandon had normal active bowel sound in all four quadrants.

    12:33 Brandon didn't have any NG tubes or gastric tubes.

    12:37 He was not connected to suction and he is content of bowel movement.

    12:42 Brandon reported that he had a bowle movement within the last day or two and the stool was within normal limits.

    12:50 Now we move on to the genital urinary, Brandon was continent and reports a clear yellow straw yellow urine.

    12:59 Now, when I assessed Brandon's lower extremities, he had strong and equal foot pushes and we would document this at a 5+.

    13:08 Now looking at his circulation, we assessed his pedal pulses and they were palpable in the right and left extremity.

    13:16 We also did not know any edema, so overall Brandon's circulation was good.

    13:22 His color of his extremities were peak and appropriate.

    13:26 He had palpable pulses.

    13:27 And his capillary refill was less than 3 seconds.

    13:31 He could feel when I was palpating his pulses and his temperature was appropriate.

    13:37 Brandon did not have any contractures.

    13:40 He did not have any amputations.

    13:42 He also was able to turn himself, set up independently.

    13:46 He reports that he's able to walk independently and set up in the bed by himself.

    13:52 Now, overall, when we're looking at skin appearance, Brandon did not have any wounds that we noted on assessment.

    About the Lecture

    The lecture General Bedside Assessment (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Assessment: Demonstration.

    Included Quiz Questions

    1. The nurse asks if the client is in pain or has any concerns before proceeding with the assessment.
    2. The nurse assesses the client’s lungs by placing their stethoscope over the client’s gown anteriorly and posteriorly.
    3. The nurse assesses the client’s capillary refill by pressing down on the nail beds.
    4. The nurse assesses the client’s pupils with a penlight.
    5. The nurse verifies the client's identification by asking for the client's name only.
    1. "Squeeze my fingers with each hand at the same time."
    2. "Stand up from the bed by pressing your hands down on the mattress."
    3. "Squeeze a pen or pencil in each of your hands."
    4. "Put your hands together at the level of your chest and squeeze your hands."
    1. Confirm the client’s identity.
    2. Document the predicted assessment findings.
    3. Administer the client’s morning medications.
    4. Listen to the client’s lungs.
    1. Ensure the bed is in the lowest position.
    2. Ensure that two bedside rails are up.
    3. Ask the client for any concerns.
    4. Ensure the head of the bed is flat.
    5. Ensure the client’s call bell is out of reach.

    Author of lecture General Bedside Assessment (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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