Hello. I'm Samantha Rhea.
Today I'm going to show you
how to do a head to toe assessment
in about 5 to 10 minutes.
I like to call this a clinical head
Now, refer back to your health assessment
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
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.
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.
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.
Hi, can I come in? Yes.
All right. Great.
I'm going to be your nurse today.
Do you mind
if I take a look at your wristband?
All right. Great.
Can you go ahead and tell me your name
and date of birth?
March 7th. 1996.
Can you tell me where you're at right now?
Hospital. All right.
Can you tell me what month you're in right
Yes, very good. Okay, great.
So today I'm going to do a quick head
to toe assessment.
It should really only take about 5
to 10 minutes.
Is that okay
if I go ahead and proceed with you? Yes.
So tell me, what actually brought you
into the hospital?
High blood sugar. High blood sugar. Okay.
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.
So no pain or anything like that? No.
So when I do my head to toe assessment,
I'll kind of walk
you through and give you some prompts.
So if you have any concerns,
please let me know.
Okay, great. So,
let me go ahead and start with your head.
If you would, I'm going to take a look
at the back of your head real quick.
Okay, great. All right. Thank you.
So I'm going to go ahead
and take my penlight.
So this will be a little bright.
I'm going to take
a look at your eyes as well.
Look right here on me. Okay, great.
And I'm going to do it on the other
So are you having any vision problems?
Blurry vision, that's weird for you.
Any eye pain? No.
So, I'm going to take a look
inside your mouth as well.
Say 'ahh' for me. All right. Great.
So what I'm going to do now,
I'd like to assess your range of motion
with your neck and your shoulders.
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.
And now up and down for me.
So now I want you to shrug your shoulders,
like, all the way up to your ears
for me. Very nice.
Now, do you have any discomfort, pain
or anything with your neck,
shoulders, any of that? No. Okay, great.
All right, so now I'm going to test
your strength on your arms.
Can you give me your arms
and raise them up for me? Good.
So I want you to squeeze
my fingers. Don't be shy.
Nice. Hard squeeze. Okay.
Squeeze, squeeze, squeeze.
All right. You can relax your arms.
So now I'm going to
just take your fingertips, and I'm going
to push just to check your circulation.
All right, you relax your arms
and I'll check your pulses real quick.
You can relax those.
So now I'm going to go ahead
and take a listen to your chest.
So I'm going to take my stethoscope.
I'm going to listen to your lungs
and your heart and the back of your lungs
as well, back side.
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.
Okay. All right.
So I'm just going with the side here.
Sorry if I have cold hands here.
And you just breathe normally.
If you'll sit up, I'm
going to take a listen in the backside.
All right, go ahead and relax.
Brandon your lungs sound really good.
Are you have any trouble
breathing, shortness of breath?
Any issues with that lately? No. Okay.
What about now?
No. No? Okay.
I'm going to listen to your heart,
so let me get back on your gown again
from the side.
And you can just relax.
sounds nice and strong and regular.
I need to take a look at your abdomen.
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.
I don't see any major
bruising or scars. Good.
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.
Start in your right side here.
So I hear good bowel sounds.
Now, let me ask you, how's your appetite?
Has that been okay?
No recent major weight
loss that you're concerned about?
What about your bowel patterns?
Like any diarrhea or issues there?
When was your last bowel movement?
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.
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.
Some patients we want to make sure
there's no excoriation or any wounds
or anything we need to address.
But now I'm going to go ahead
and move on to his legs.
So let me go ahead and move on your legs.
And if that's okay, I'm
going to pull back the covers,
and I'm just looking for any swelling.
I'm just going to push on them.
Okay, I'll pull these down
so you won't get so cold.
All right, good.
So now I'm going to assess your strength.
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.
So lift that for me. Good.
So on the count of 1, 2, 3, 4, 5.
Very nice. All right, we're going to do it
with the other one as well.
So, 1, 2, 3, 4, 5.
So now I want you to push like you're
pushing on the gas.
So now I want to pull towards your face.
Very nice. Okay.
And I'm just going to feel
the bottom of your heels
and make sure we don't have anything
breaking down here.
So, I'm going to just check your
circulation in your toenails.
Let me assess your pulses.
So that finishes up
our assessment Brandon, thank you!
I appreciate it.
Is there anything else I can do for you?
Before I step out? No. Okay.
So when we finish up our head
to toe assessment,
there's a couple of things to remember.
You know, when we walked into the room,
you can see that Brandon's already
He's responsive. He's not in any distress.
Also, at that time would be a good time
to check for
any drains or tubes
and make sure you assess those.
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.
Thanks for watching.
done a physical assessment
on our client, Brandon.
I'd like to show you an example
of how we might chart
that or what
a charting might look like on the patient.
So we've got a male client with the age of
about approximately 30 years old.
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.
Now, when we are doing assessment
on our client, Brandon,
his facial expression was calm.
He was cooperative
and willing to answer questions.
Now, when we're taking a look at Brandon's
let's take a look
at his level of consciousness.
So he was alert, awake
and responsive to questions.
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.
He was also responsive to voice.
So we're overall looking at Brandon's
He did not complain of a headache
so that was great.
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.
He also does not use
any assistive devices for his hearing.
Now moving down to Brandon's mouth:
His teeth were healthy.
They were intact.
Also his mucous membranes were moist
and intact as well.
And general appearance for his skin
on his head was pink and intact.
When we focus in on Brandon's eyes,
he had good
vision and good visual eyesight.
We take a closer look at his pupils.
They were equal, round
and reacted to light.
And we had a consensual
response, which is positive.
Brandon's pupil size
before the penlight light
was 4 millimeters
and after the light
we documented at 2 millimeters.
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.
And this was not visible.
Now, after we've assessed Brandon's neck,
we're going to move down to the chest.
So we assessed Brandon's heart rhythm.
It was regular and there were strong
sounds of S1 and S2.
Now, when we're documenting respirations
There were regular, even, unlabored,
Now, on auscultation
when we listen to Brandon's lungs,
they were clear in all upper and lower
and Brandon didn't have any cough.
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.
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.
And checking capillary refill in
both the right and left arm extremity.
It was normal.
And overall, Brandon's arms,
the skin was intact, the color was normal.
We didn't see any tinting
that is a sign of dehydration.
His skin was warm and it was dry.
Now, on Brandon's arms that we had,
as you just heard, good circulation.
We saw pulses, a normal cap refill.
And he was able to feel
when I was assessing his pulse
and the temperature was normal.
Brandon was also able
to move around his arms
as active range of motion,
and this was within normal limits.
Now moving from chest down to the abdomen.
Brandon's abdomen was soft, flat
and not distended.
Also, Brandon had normal active bowel
sound in all four quadrants.
Brandon didn't have any
NG tubes or gastric tubes.
He was not connected to suction
and he is content of bowel movement.
Brandon reported that he had a bowle
movement within the last day or two
and the stool was within normal limits.
Now we move on to the genital
was continent and reports a clear
yellow straw yellow urine.
Now, when I assessed
Brandon's lower extremities,
he had strong and equal foot pushes
and we would document this at a 5+.
Now looking at his circulation,
we assessed his pedal pulses
and they were palpable
in the right and left extremity.
We also did not know any edema,
so overall Brandon's circulation was good.
His color of his extremities
were peak and appropriate.
He had palpable pulses.
And his capillary
refill was less than 3 seconds.
He could feel
when I was palpating his pulses
and his temperature was appropriate.
Brandon did not have any contractures.
He did not have any amputations.
He also was able to turn himself,
set up independently.
He reports that he's able to walk
independently and set up in the bed
when we're looking at skin appearance,
Brandon did not have any wounds
that we noted on assessment.