How to Do a Head-to-toe Assessment (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 Now, when we start talking about assessment, here's a few really important tips to keep in mind as you're working through it.

    00:09 Now just know, as a nurse, there's different ways that every nurse kind of does their assessment.

    00:15 But keep in mind, you want to be systematic, meaning you have a method and a way that you make sure you're doing it the same way each time.

    00:23 This way, you'll cover all your body systems.

    00:26 Now, one really popular way is what we call head-to-toe, that makes it really easy to make sure you're hitting all those important body systems.

    00:36 Now, don't forget when we are going head-to-toe, or systematically, when we're assessing our patient, you've got to compare sides, right? Because you do have two arms, you've got two eyes, you've got lung field on each side.

    00:50 It's really important that we compare here because there can be differences.

    00:55 So, some examples I'm talking about is like lung sounds for example, you may think, "Okay, they should sound the same." But indeed, a lot of the times depending if it's your trauma, for example, they may not.

    01:06 So, what I mean by this is, let's say you listen on the right side of the upper and lower lobes of the patient.

    01:13 Maybe they really don't have a lot of air movement, when you listen to them on inspiration and expiration.

    01:19 You could barely hear that breath.

    01:21 Now, when you listen, on the left, it sounds great, you hear a full inspiration, full expiration.

    01:27 Now, that's different, right? From the right to the left.

    01:31 That could mean there could be a collapsed lung or something else going on with the patient and we need to assess that. And as you can see, right versus left is different.

    01:40 Now, here's another - other really important time that this comes into play.

    01:45 Stroke patients in particular, a lot of the times, I used to work on a stroke floor.

    01:50 And as you can imagine, depending on the side of the brain that's damaged, the opposite side can be affected.

    01:56 So, you may have weakness on one side of the body.

    01:59 Again, this is where comparing sides is important and of course, just kind of keep an eye on the neuro status.

    02:06 Looking at the difference of the pupils, there can indeed be some changes on one side versus the other.

    02:12 You can have two different sizes of pupils.

    02:15 Sometimes, this is emergency, sometimes it can be normal for the patient.

    02:18 But be sure to compare sides.

    02:20 Now, recording notes when we're talking about organization is really important.

    02:27 As you can imagine, there's a lot of patient data going on.

    02:31 So, one key way to do this to make sure you've got the right information with the right patient is recording at the bedside computer if this is available at your facility.

    02:41 So, this is really the standard of care.

    02:44 We perform our head-to-toe assessment, we document in the room with our patient, we can have a conversation with them, such as, "Have you had a bowel movement recently?" And this includes the patient in on their care as well.

    02:57 The other thing to keep in mind, if this is not available, think about all of the different patients you may assess.

    03:04 So, a great example is maybe I have five patients on the medical surgical floor, I can't memorize every single assessment detail on one room, then the second room then the third room.

    03:16 So, it's important that you record notes and keep track of details.

    03:20 So, when we're talking about assessment, now, there are four techniques that we use.

    03:27 Now, what are the four basic physical assessment techniques that we use, and these are the big ones.

    03:33 So, we call these the Big Four and these are the types of ways that we perform head to toe assessment or gain information.

    03:41 So, one of those is one of the easiest, which is inspection.

    03:45 Now, we kind of talked about this earlier when we're talking about eyeballing and visually looking at our patient, so inspection is great.

    03:52 It actually - we tend to underestimate this, but we can see a lot, especially with more experience as you gain as a nurse, inspection gives us a lot of really important patient condition information.

    04:05 Now, palpations a little bit different.

    04:08 This is more thinking about feeling with your hands, you're really using your hand and what we call palpate and feel.

    04:15 Now, this is really important.

    04:17 Let's say if you're using an abdominal assessment, and we start palpating and feeling.

    04:22 We're going to see does the patient wince or move away from that pain or seem to be tender when we push.

    04:30 Now one thing I want to talk about palpation, if you see an abnormality and you're not sure what it is, my recommendation is do not palpate it.

    04:40 So, there are certain tumors especially in the pediatric or the baby population that you do not want to palpate this particular tumor or mass, if you're not sure alert your doctor.

    04:52 Now, next is percussion.

    04:54 This one's a little bit different and you may not see this quite so often with bedside nursing.

    05:00 It just really depends on where you work.

    05:03 So, percussion is, as you see in this image, where you're going to tap with fingers, or maybe hands to feel around the borders of an organ in the body.

    05:11 Now, you're listening for different symphonies and different sounds here.

    05:15 Now, and again, this is really helpful for specific type and advanced physical assessment.

    05:21 But again, bedside nursing, we don't use this quite so much.

    05:25 And next is where we get to use what we call our ears, otherwise known as our stethoscope.

    05:31 Now, this is the practice of auscultation, meaning we're listening.

    05:36 So, we're using our stethoscope here and looking at different and listening to different parts of the body. We can pick up all kinds of important assessment details.

    05:46 Now, one thing before we leave this big four, so typically, we use these four things to help us gather information.

    05:54 Just know when you're talking about an abdominal assessment, specifically.

    05:59 Now the order is a little different.

    06:01 You want to look at - look at the stomach, and the skin and everything with your eyes and perform inspection.

    06:08 Then we want to use our ears and listen to those bowel sounds.

    06:12 Then we can percuss if indicated, then we palpate.

    06:17 Now, the reason why we look and listen first, because we start pushing around on your stomach.

    06:23 If you take your stethoscope and take a listen after I've been pushing around, it'll probably artificial, you'll start hearing a lot more gurgles and movement.

    06:32 When that's not really the most natural, bowel sounds that you should hear from your patient.

    06:37 So, when you're talking about abdominal assessment, so look and listen before you touch your patient's abdomen.

    06:44 So, now let's look at how we divide up a head-to-toe assessment and again, every nurse practice is a little bit different but this is a great guideline to check on your body systems.

    06:55 So, if you take a look here at the top, when we look at the head and divide this area, we're looking at the central nervous system.

    07:02 We're seeing their level of consciousness or orientation, we see their skin, their eyes, their nose, all of this in the head area covers quite a bit.

    07:11 Then, if we move from the head down to the chest, we're going to capture our respiratory and our cardiovascular system by listening and feeling, listening to our heart and our lungs.

    07:23 Now, if we're just moving on down the body.

    07:25 Now in this section, when I think about stomach, I always think, this may sound a little bit weird, but I always think about don't forget pee and poop.

    07:33 So, you're thinking about the GI system, bowel sounds, movement, bowel movements, for example, diarrhea, any of these issues, and then moving on down to the GU system, which is our urinary system.

    07:47 So, when I get to this stomach, I just think pee and poop meaning when's your last bowel movement? Are you having any pain? How's your bowels been? When's the last time you voided, you urinated? How did that look? Next, as we've been moving down, don't forget the all-important largest organ of your body, which is the skin, right? So, all while we're moving from head to toe, we're capturing all these skin pieces and these skins assessment as we're moving down in seeing if we see wounds or lacerations or any abnormalities.

    08:21 Now, as we move through our patient, sometimes, this can be assessed because your patient may naturally be moving, but we want to keep in mind their musculoskeletal system and their mobility.

    08:32 Can they move their arms and legs? Are they really weak? Do they need assistive devices? And don't forget any IV lines, drains or tubes as we're moving from head-to-toe.

    About the Lecture

    The lecture How to Do a Head-to-toe Assessment (Nursing) by Samantha Rhea, MSN, RN is from the course Nursing Assessment: Demonstration.

    Included Quiz Questions

    1. By comparing one side of the body to the other
    2. By working from the top of the client’s body downward
    3. By recording the assessment at the bedside if possible
    4. By assessing only the body systems affected by the client’s chief complaint
    1. Inspection
    2. Palpation
    3. Percussion
    4. Auscultation
    5. Phlebotomy
    1. Inspection, auscultation, percussion, palpation
    2. Inspection, percussion, palpation, auscultation
    3. Percussion, inspection, auscultation, palpation
    4. Inspection, palpation, percussion, auscultation
    1. Integumentary system
    2. Genitourinary system
    3. Gastrointestinal system
    4. Eyes, mouth, nose, and ears

    Author of lecture How to Do a Head-to-toe Assessment (Nursing)

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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    helpful preamble to head to toe
    By Karen S. on 24. April 2022 for How to Do a Head-to-toe Assessment (Nursing)

    the organization with listed infographics were very helpful to reinforce the logic of head to toe, and was a good summary for head to toe assessment