Head-to-toe Assessment (Nursing)

00:04 Welcome to the skills video of how we perform a head to toe assessment.

00:09 Now, I'm a practicing nurse and I would love to show you how we do a systematic method of going indeed from head to toe to perform an assessment on our patient here with Brandon.

00:20 Now, we're going to show you skills on how to move through this assessment.

00:25 But just note, we're not going to go through each and every assessment detail.

00:31 Now, we have specific resource videos for you to refer to.

00:35 Now, a couple of things to remember.

00:37 Now, when you're learning an assessment in nursing school, now, often you hear instructors and during your health assessment course, segment everything such as neurological, and then musculoskeletal, and then cardiac.

00:50 But really, in real practice, many times I just do this all at once and again, in a systematic fashion from head indeed to toe.

01:00 Now, in real life, you're going to be asking questions as you go, and you move from head to toe with your patient.

01:06 And again, this is not going to be shown here.

01:09 But this is referred to in other assessment videos.

01:12 As I begin my head to toe assessment as a nurse, one of the first things that we do before we start our assessment is when I enter into the patient's room, and before I start assessing from head to toe, make sure you introduce yourself.

01:27 And it can just look something like this.

01:29 [Samantha] Hi, I'm Samantha. I'm going to be your nurse today.

01:32 Can you go ahead and give me your name and date of birth? [Brandon] Brandon. March 7th. [Samantha] Okay, perfect.

01:37 And would you like to go by Brandon or Mr. Smith? Do you have a preference? [Brandon] Brandon.

01:42 [Samantha] Brandon. Okay, perfect.

01:44 So, just by doing this, I'm just making sure I involve my patient and what their preferences with our care together.

01:51 Also Brandon, can you tell me, what day of the week? And what brought you in the hospital? Why are you here? [Brandon] It's Monday. I was in a car accident.

01:57 [Samantha] Perfect. Oh, man. Okay.

02:00 So then here, we're assessing our cognitive status very quickly with our patient.

02:04 Now, it's a good idea during this step, as well, when we're talking about assessment is just that let Brandon know that he may need to participate during the assessment.

02:13 And as a nurse, you want to watch and listen and look for the responses from your patient.

02:19 Now, formally, as you can see, in that very quick interaction, I can see as I walked into the room, and even before we started, that I could see Brandon setting up right, he's awake, he's alert.

02:31 And during our quick conversation there, I already could see that Brandon is coherent, he's accurate in his information, and he's able to quickly and verbally respond.

02:43 Also, at any point, if Brandon wasn't really a very awake or alert, he wasn't with his eyes open, then that would be a good time to see if Brandon can move his extremities or maybe grasp my hand, or if he's withdrawing from any sort of pain.

02:58 If he wasn't in the same cognitive status, as you see here, as awake and alert.

03:04 Now, as I start my actual physical assessment with my patient here, we're going to start indeed, at the top here at the head.

03:11 Now, as you can see, I'm going to take just a quick scan of Brandon's face his head here and check all of those important points.

03:18 Such as just looking at his hair, I can see it's clean, it's healthy.

03:23 Also, don't forget that if your patient has any sort of device, such as a breathing tube, or oxygen, which is really common, make sure that you check those point of contact.

03:35 This can wear down the skin and cause ulcers, so we want to make sure we check that.

03:39 The other thing to keep in mind -- now if you remember, Brandon came in with a motor vehicle accident.

03:45 So we want to be diligent in checking, did he have any bruising or lacerations? Or did he look like he had any breaks? And lastly, don't forget about the coloring just of the lips and the skin.

03:57 Now, as you can imagine, if I walked in and Brandon and look really pale, or if his lips were blue, this is a bad sign that he's not getting appropriate oxygenation.

04:07 Now, that we've assessed the general appearance of the head on our patient.

04:11 Next, I'm going to move with Brandon's eyes.

04:14 So here is where we assess what we call the pupillary response.

04:17 So this is where we get to use the fun part that penlight that you're always asked for nursing school.

04:22 Now, this is actually going to be really helpful on certain traumas, or any neurological floors, or neurological patients.

04:30 So one of the things that we actually use is what we call a penlight.

04:34 So this is really helpful because it's important to note the size of the pupils.

04:39 Now, we're actually going to note the size of the pupils and compare them to our guide when just the patient's at rest, with no certain light and at this point.

04:49 Now really, what we're just using this light for is to make sure that when I shine the light in Brandon's eyes, that both of those pupils constrict.

04:59 So, it's going to look like this.

05:01 So, I'm just going to take my penlight, I'm going to push down. And just by looking at Brandon, I can get a good idea about what his pupil size is.

05:08 Then I'm going to take my light and illuminate it.

05:12 And I'm just going to have, "Brandon, will you look right here for me? Perfect." So, I'm going to take my penlight, and guide it down one pupil.

05:19 Now, when I do that, I see that when I bring the light here, both pupils constrict, and then I can repeat it on the other side.

05:28 We're just looking for that bilateral, consensual, pupillary response.

05:32 The other thing we look at for eyes is, is he tracking? All that means here, and as you can imagine, when you walk into a patient's room, their head and their eyes are following you around.

05:44 That's an easy way to assess tracking.

05:46 Now, there are some variations when we're talking about pupil size, and things like that, there can be a lot of abnormalities that need to be reported.

05:56 Now, once we've assessed Brandon's eyes, we're just going to move down and look in the mouth.

06:01 So this is actually really underestimated.

06:04 I find it very important as a nurse to assess a patient's mouth.

06:08 In particular, I used to take care of stroke patients, and many times, there's a lot of different bacteria or fungus back there that makes it really hard for swallowing.

06:20 So we're going to check for deformities.

06:22 This is a great time to pull out your penlight again, and I'm going to take this.

06:26 "And Brandon, will you open up your mouth for me? Great." So, I'm just going to look through.

06:34 Perfect.

06:35 So, when I assess Brandon's mouth, all I'm really looking for is dentition.

06:40 Is there a lot of like lacerations, or redness, or swelling, on Brandon's lips? His tongues? In the back of their throat? I'm also looking for any white, that could be any sort of thrush or infection, for example.

06:54 Now, is there something in the back of his throat that sometimes gets caught up and harden and then it makes it hard to swallow.

07:01 And it's also important to note the cleanliness of his mouth and teeth.

07:06 Now, after we move past the mouth. Now we can go through the throat.

07:10 And as I was looking down there, I was assessing the mouth part.

07:13 But when I'm looking just from head to toe, when I look at Brandon's throat, what I'm really looking for is that trachea wise down the middle is for alignment, I don't see any abnormalities.

07:25 This is a good time as well, when you're talking to your patient and have a naturally swallowed, to see if there's any abnormalities or difficulties.

07:34 And sometimes on your assessment, depending on what you're looking for, it's also appropriate to palpate for his carotid pulse.

07:41 So where we would do this is and during the CPR cycle, this may be a time that you do that.

07:47 So, if you go about midway between the middle and the front of his throat, and use your fingers, and palpate for the carotid pulse.

07:56 So it's really important here that we're not pushing down really hard and restricting blood flow.

08:03 So now, that we've gone head to toe, and don't forget all while I'm doing this visual scan, I can see Brandon's ears, any odd drainage or anything like that, that we can assess as well.

08:14 Now, once I moved from the head down to the throat, this is a great time as I've been working through my assessment to check the chest of our patients.

08:23 So, we're going here, and we're moving down.

08:25 Now, during this time and throughout this assessment, I can look at his rate, the quality of his breathing, how deep he's breathing, we want to look for some key things.

08:36 So, Brandon looks like he's resting comfortably, breathing easily, but if I saw Brandon, breathing fast and labor, and having difficulty that's important to know.

08:48 Also think about that if you see his, retract, any sternal retractions, that's also abnormal.

08:56 So one thing just to think about, think about how you breathe when you're relaxed and easy, that's what you should see here on your patient like Brandon.

09:04 Now, when you're talking about the chest, depending on any kind of surgery they may have had, you need to double check as well that is there any chest tubes, any sort of drainage tubes coming out? If that's the case, we definitely have to look around the insertion site and see, what's the color of the drainage going through the tube? What about the insertion site? Is it red? Is a swelling? Is there any sort of pussy type of things coming out? If that's the case, definitely need to check that as well.

09:34 Now, if the patient, if Brandon here specifically had a chest tube, for example.

09:38 We need to make sure we look around this and palpate for what we call is crepitus.

09:43 Meaning there's bubbling or some edema and some excess fluid under the skin, around that tube.

09:50 Now, if that was the case, this is also abnormal, and we need to report this.

09:56 Now, that we've talked about the general assessment of the chest and the observation, now, we actually get to use our ears.

10:03 So when we do this, we call it auscultation of the lung sounds.

10:07 So anytime you hear that word nursing school auscultation, it means to listen.

10:12 So here's a really important point to note.

10:15 And many times you're going to see nurses do this, but it's really important to listen to the front of our patients chest, Brandon here, and also the back.

10:24 Now, we're going to do this because sometimes you can't catch stuff in the front, and you may indeed hear abnormalities in the back in the basis of your lungs.

10:34 Also, make sure you compare side to side.

10:37 So you want to know when you're listening, is there anything crackly sounding and kind of like rice krispies, or any sort of like high-pitched, abnormal sound like asthma.

10:48 Anything abnormal, you want to document and also report.

10:52 Now, I'm going to show you how we're going to auscultate the front and the back of Brandon's lungs.

10:57 Now, just for this demonstration, we're actually going to listen over the gown, but just so you can see where I placed my stethoscope.

11:05 Now, as you can imagine, now, if I listen around here, you can imagine when you're trying to hear, you're going to pick up all this shuffling and all this noise from Brandon's gown.

11:15 It's really important you go stethoscope to skin to listen to your patient.

11:20 It's going to be a much better assessment.

11:23 Okay, so just to start when we're listening to Brandon's anterior or front side of his lungs, you know, put in my ears.

11:30 Now, when I do this, and I auscultate, "Now, Brandon, I'm going to just kind of listen on each side of the chest.

11:37 I want you to relax and breathe normally." What we don't want here is that Brandon, to tell them to breathe and go and hyperventilate, this can wear out your patient, and make it very difficult for you to hear and for them to maintain.

11:51 So just have them breathe easily and at rest.

11:55 "Okay, so Brandon, I'm just going to take a quick listen here." Now, when I'm listening to Brandon, as you see, every inspiration and expiration is one breath.

12:15 And again though, I know I'm going over the clothes, but make sure you go skin the skin.

12:22 So that way, you don't pick up all the sounds of Brandon's gown when you're listening.

12:28 Good.

12:32 Good. Okay, great.

12:33 So I've listened to the anterior part of Brandon's chest.

12:36 And when I did that, you saw that I went systematically from side to side.

12:40 And just kind of basically split the sternum there.

12:43 Kind of at this midline here.

12:46 "Okay, Brandon, so what I'm going to do is listen to your backside, if you would.

12:49 Do you mind just shuffling your feet on this direction, so I can get to your back? Perfect. Thank you so much." Now Brandon, couldn't do this, you can have him lean up in bed, or even roll to a side if you need to access his back.

13:07 Okay, the lesson here, it's going to be about the same method.

13:10 So, I'm going to kind of split Brandon spine here and listen on each side.

13:16 And we're going to listen with each inspiration and expiration as one.

13:21 And move from top to bottom.

13:26 Now, this is really important here, because many times like if you have a patient with pneumonia, for example, sometimes you can't hear abnormal lung sounds such as crackles on the front, but you can sure hear at down here in the bases in the poster or backside.

13:41 Perfect, good. Thank you, Brandon.

13:42 You can go ahead and lay on back for me.

13:47 So this is also really helpful because you can also see the natural chest rise and fall for Brandon.

13:52 Now that we're here and we've listened to the lungs, now we can go ahead and listen to the rest of the chest, which is Brandon's heart.

13:59 So when we're doing this, we're listening to that lub-dub as one, lub-dub as two.

14:04 And many times when we listen, there's certain medications and things like that, that you need an accurate pulse and we listen to the apical or the pulse here.

14:14 Now, when you're listening, you want to listen to the rate.

14:18 Meaning how fast is it? Or is it very slow? Also, does it sound like a regular rhythm? Meaning does it just tick, tick, tick, on time? Or is it abnormal, like tick-tick, tick, tick, tick-tick.

14:35 So if it's abnormal, that's also something to know.

14:37 The patient can have an irregular heart rhythm or heartbeat.

14:41 So when I listen to Brandon's heart, I want to listen to for what we call S1, S2, or that lub-dub, lub-dub.

14:50 When I listen, I'm just going to split about the midclavicular line and take a listen to Brandon.

15:06 Okay, perfect.

15:08 So when I'm listening to Brandon, I can hear that lub-dub, and listening again for an ample amount of time, for a atypical heart rate if you need to get that, and that normal rate and rhythm.

15:19 Now, some patients, if they have a history of something irregular, take plenty of time, at least a full minute to listen.

15:26 Now when we're talking about assessing the rest of Brandon's chest, it's a good idea. Don't forget to look at the skin.

15:33 So especially in your female patients, maybe under the breast line, look for redness, excoriation, also special with our patient here, if they were in an accident, look for any signs of bleeding.

15:46 So look up on the back, on the chest, up in the upper flank area, you see any abnormal bleeding or bruising, you want to report that as well.

15:56 So now that we've moved from our patient's chest, we've listened to their heart, listen to their lungs, now we can move down to their abdomen.

16:03 So here's the really important thing to remember is when we're talking about an abdomen, when we go to inspect, we can look, then we want to listen, then we want to percuss, or palpate.

16:17 What I mean by this, is you don't want to go pushing on around Brandon's abdomen, because when I go to listen, that can stir up those bowel sounds and that's not his true natural bowel sounds that we need to assess.

16:31 So when I go to assess Brandon's abdomen, Go ahead and pull down your gown here for me.

16:38 So I would raise Brandon's gown up and look here on his abdomen.

16:42 Does it look distended? Now, is there any abnormal coloring? Is there like a yellowish? If do I see any signs of bleeding or bruising, or anything abnormal.

16:52 The other thing, this is a good time when you're inspecting the abdomen.

16:56 Sometimes your patient has certain type of drains such as an ostomy that you want to check.

17:01 Are there any signs of drainage or any signs of infection such as redness, or bruising, or any sort of pus? Now, one more thing to know, is when we're talking about inspection of the abdomen, sometimes you may see in the abnormal bulging, such as a hernia, and you want to report that as well.

17:19 So that's kind of some of the general things that we would look just to see if the skin integrity and all of that looks normal, and check for any drains.

17:28 And of course, don't forget about any signs of infection.

17:31 Now after inspection, now we remember to auscultate, which means listen before we actually touch.

17:38 So anytime you auscultate, here's an important point to know.

17:42 Think about your abdomen and four Tic Tac Toe pieces of the pie.

17:46 So when I'm looking at Brandon's abdomen, I want to split this down the middle, and across.

17:53 It's important that we assess all four quadrants of Brandon's abdomen.

17:58 Now we're going to take a look here.

18:00 Does it sound really super gurgling, tumultuous? We call that hyperactive.

18:05 Or does it sound very soft with a little bit of gurgling, we call that hypoactive.

18:12 Now sometimes when we listen, if we can't hear anything, that's an abnormality and you definitely want to note that.

18:19 We also want to know if you will hear any gurgling, or anything high pitch, or any sort of whooshing sound.

18:26 Anything like that you want to know and document in your assessment.

18:31 Now just note, because everything's local, and when I listened to Brandon's abdomen here, you may hear some of the heartbeat as well and that's totally normal.

18:40 So now, I'm going to show you how we auscultate Brandon's abdomen.

18:46 Okay, when I go to auscultate after I've inspected of course, I'm going to go the right upper quadrant here.

18:53 And you only have to listen until you hear bowel sounds.

18:57 Now, it may take a little bit of time for bowel sounds to be heard.

19:02 You need at least listen to a good couple of minutes and wait to hear bowel sounds.

19:14 Good. Thank you.

19:16 So when I listened, were listened to right upper, right lower, left upper and left lower quadrant.

19:23 So after we've inspected really important with the abdomen, we've auscultated then I can palpate the abdomen a little bit.

19:31 "Brandon, are you having any pain or anything like that?" [Brandon] No. [Samantha] No? Feel comfortable? Okay.

19:35 If you saw me push down on, or palpate Brandon's abdomen he started guarding or wincing, that could be a potential issue and you want to document that.

19:44 Now that we've moved through Brandon's abdomen here we're going to look at his arms.

19:49 So here with his arms, we can see these are appropriate color.

19:53 We don't see any lacerations or bruising.

19:56 We don't see any light deformities, for example, especially in the hands.

20:00 Now, where you may see this as if you have an elderly client with maybe arthritis, those nodules, or anything like that.

20:07 So we want to check through Brandon's arms look healthy.

20:10 We don't see any abnormal skin assessment.

20:14 Also, if Brandon had any IV sites or any lines, make sure to assess those and those insertion sites.

20:21 Do I see any streaking, redness, or pus? Do I see any redness is that hot to the touch? That's the case, we want to check that.

20:29 And of course, we want to feel skin looks great, it feels nice and warm, it feels healthy, good muscular tone.

20:37 And then we want to palpate our pulses.

20:39 If we palpate our pulses, you can check here up in the brachial area, and bilaterally.

20:45 Then we can check both in the radial pulses.

20:48 Nice thing about assessment when you're moving this through a lot of the times, I can just do both of these radials at the same time.

20:55 Now, this is a very easy thing to practice, when you're checking pulses.

20:59 You go down the thumb side, just kind of very gently, flat, not like this, and palpate pulses.

21:05 You can feel that easily with your patient.

21:09 Now, that I've went through that, I want to check the strength of my patient.

21:12 So really easy way to do it.

21:14 "Now Brandon, I'm going to put out two fingers, I want you to grab, go ahead and squeeze for me.

21:19 Don't be shy. Very nice. Good." So here I'm assessing Brandon's strength.

21:25 Also, do you notice when I asked Brandon to squeeze, he was able to easily move up his arms, squeeze and follow those commands. That wasn't an issue with Brandon.

21:35 So I can see he's coordinated, he's got that strength.

21:38 Also know that sometimes if someone's really weak, because of illness, or whatever that is, sometimes they may not be able to squeeze or raise their arms, that could just be the sign of weakness.

21:51 Now as I move through my head to toe assessment, I'm starting at the lower half of the body now and starting with the pelvis.

21:58 So you've just got to be key about when this is important to note, especially with a patient like Brandon, that was in a motor vehicle accident.

22:06 But make sure you assess when it's appropriate.

22:09 So one thing we may need to inspect is coloring in the skin.

22:13 So, is there bleeding? Is there any bruising or some sort of lacerations? Also, sometimes it's appropriate in the trauma to palpate.

22:21 But make sure that you don't do this, if you were not trained.

22:25 They may do this just as check for stability.

22:28 But again, it may need to be deferred to the physician.

22:32 So now we're going to move down and assess Brandon's legs.

22:36 Now, this is an actual an area that people really frequently overlook.

22:41 It actually tells us quite a bit.

22:43 So when I'm inspecting Brandon's legs, I want to make sure I look at the skin covering.

22:48 It's also a good idea and many times we don't.

22:50 You want to check the patient's feet, And so it's important to remove their socks as well.

22:57 Just going to remove these. Thank you, Brandon.

22:59 Okay. So when I'm inspecting his legs, I'm looking for color here.

23:03 Is there any discoloration? Do I see any lacerations or bruising? And the other thing, is we want to check the skin and the toenails as well.

23:13 Now, if need be, and you're worried about circulation, you can check capillary refill on your patients nails by simply pushing down in applying pressure and letting go.

23:25 And then within three seconds, the color should return back to normal.

23:29 So that's just a one way that we check circulation.

23:32 And also feeling for warmth, as well and any excess moisture.

23:38 So again, upon inspection, one thing really to note about color.

23:43 Now, certain diseases with patient like venous or arterial disease, you may see a lot of redness, or you may see a lot of dark and purple color on the shins here.

23:54 And that's important to know.

23:55 Now, we also want to look for any deformities, especially if they were in a traumatic accident and edema.

24:02 That's a biggie.

24:03 So I want to check on my patient's legs.

24:05 And one way we check for edema is by simply grabbing here, our specially around the sock area and just holding and see if we see any indention.

24:16 Now, when we assess for edema, just a simple way to do so if Brandon's legs were really edematous, which for him, if I push down, there is no hardly indention whatsoever.

24:28 But if I push down, and I counted one-one-thousand, two-one-thousand, three-one-thousand and it took that long to return to normal, we would call that three plus edema, or two plus depending on how long it took to return to normal.

24:45 Now, here's another really important area to assess, especially in your diabetic patients.

24:50 We need to check on the heels, and make sure they're not boggy or soft.

24:55 We also need to make sure we check for any diabetic ulcers or little pressure ulcers on the feet.

25:01 Now before we get too much further in regards to the feet, we want to check for pulses.

25:07 And this is really important and a good thing to practice as a student.

25:10 So we want to check, and if you kind of go between Brandon's big toe and his second toe, and just anytime we palpate keep those flat, go down with about two or three fingers and palpate for what we call the dorsalis pedis and check for circulation.

25:26 And again, anytime you're working down the body, you've got two hands, you can assess at the same time.

25:33 Now we're checking if it's thready or bounding, and we want to make sure absolutely that it's present.

25:40 Now, you can check the dorsalis pedis.

25:43 And you can also check what we call the posterior tib here as well and check for circulation.

25:49 Now, once we've done that, one of the things also before we move on from the legs is you want to check for strength.

25:55 Now, one thing I like to do with our patients is have them push down like they're pushing on the gas.

26:01 So Brandon, if you will push on me like you're pushing down the gas. Perfect.

26:06 Then I'm going to put my hands up here and have Brandon pull towards this face.

26:10 Alright, point your toes and pull towards your face.

26:13 Perfect. Very good.

26:15 Now that's a really easy way as the push-pull to assess for strength of the patient that's in the bed.

26:21 The other thing you can do, you can have them lift their leg one at a time.

26:25 So I may do something like this.

26:26 Okay, Brandon, I'm going to have you put your left leg up to my hand, and I'm going to count to five, and keep it up there.

26:32 One, 1002, 1003, 1004, 1005. Excellent.

26:38 So we would repeat the same thing on the other leg.

26:42 And one thing we can do as well for strength and then check coordination.

26:47 Now, if you can take your heel and kind of rub up and down your shin with the opposite heel. Perfect. Very good.

26:54 Thank you, Brandon.

26:55 And then we would have him repeated on the other side.

26:58 Now, just note, anytime if a patient's really ill or they're really weak, and they cannot do the heel to shin, this does not mean that they don't have coordination.

27:11 That just means they have a really reduced strength.

27:14 Now that I finished assessing Brandon's legs, now here we check for coloring, checking for circulation and strength, then I cover him back up for comfortability.

27:25 Then don't forget to make sure you assess your patients groin and buttocks when appropriately.

27:30 Now, we've got to be ensure that we inspect for coloring or discoloration, any sort of bruising, excoriation, or pressure ulcers, that's a major issue for many clients, especially when they're ill.

27:44 Now many of these can come up on any pressure point, especially in the backside at the top of the buttocks in the sacral or the coccyx region of your patient.

27:54 Now, also assess that sometimes there's a particularly foul smell from this area that we want to assess this and this could be a hygiene issue, or the patient's inability to care for themselves.

28:06 And lastly, if there's any indwelling catheters, make sure you are diligent to inspect this as well, especially around the insertion side.

28:14 And check that line for any kinks or tubings and it's draining appropriately.

28:19 Thanks for hanging out with us today in the head to toe assessment.