Importance of a Head-to-toe Assessment (Nursing)

by Samantha Rhea, MSN, RN

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    00:01 Welcome to the course of health assessment.

    00:04 Now, we're going to discuss how nurses assess a client on each shift.

    00:09 Now, really, we're going to dive in on how we perform this skill and this is arguably one of the most important things that we learn as a nurse.

    00:18 Just note with a health assessment, that we can detect early changes in a client condition and even prevent an emergency.

    00:27 Now, let's talk about you going on shift, you received your shift report.

    00:32 Now, let's take a look - now, where do we go from here and what do we do? So, when we start as a nurse at the beginning of each shift, we've got to think about, we've got to complete a client assessment.

    00:45 So, let's talk about a few important pointers of why we do this.

    00:49 So, why we do a shift assessment at the beginning of our shift.

    00:54 This is going to give us a really good idea of the client's current health status and the baseline for their shift.

    01:01 That way, if something changes later, we will know about it and we'll know the differences and what has changed.

    01:07 Also, don't forget about your bedside shift report.

    01:10 So, this is common for safety in most practices.

    01:14 We're gonna be able to validate the information that we get and we're going to be able to see visually about some of that information with our client.

    01:22 Now, as we - as we are assessing our patient, we're gonna be able to identify some really important interdisciplinary care priorities.

    01:31 Now, this could be anything from we assess something in our patient and we've got to promptly report it to our doctor.

    01:38 Or let's say overnight, you get information that the patient had trouble swallowing or you assess this in the morning with your assessment.

    01:46 You may have to contact speech therapy to address these issues.

    01:51 And next, when you're talking about client assessment, this is really important because it gathers all kind of information to guide our clinical judgment and our decision making, and most importantly, think about if you have a team of patients, four or five for example, or even two or three.

    02:09 What that does by getting an assessment, it helps us guide our judgement and prioritize our patients.

    02:16 And of course, evaluation is a big part of nursing, right? We're gonna be able to evaluate the progress of the client and what those outcomes are from their treatment.

    02:26 Now, when we start talking about going into assess our patient, we've gotta ask our question, "Well, what do we even see?" So, first thing when we walk into a client room, we do something that we call, eyeballing the client.

    02:40 It indeed is just that. Literally, we're laying eyes on the patient and we just kind of think this as, we are visually scanning the patient.

    02:49 Now know, this is different from a full head-to-toe assessment where we use our stethoscope.

    02:54 First thing we do, right when we come into the room again, is eyeball and scan your patient.

    03:00 Now, this is a really great time to do this, when the night shift maybe is leaving.

    03:05 I'm as day shift, we're doing a bedside shift report with our patient and including them in care. Now, this whole time, I'm eyeballing the patient.

    03:14 Now, this happens first before I even touch the client.

    03:18 This is when I come in with the night nurse, I introduce myself, I ask their name.

    03:23 And just in that very short time, when I'm talking, eyeballing the patient, I can even see their level of consciousness, right? I can see if the patient's awake, and alert and responsive, and just by eyeballing the client.

    03:37 I can see, is my patient resting? Are they breathing comfortably? Are there any signs of distress or pain? And the other thing I can see, of course, is any tubes, drains, IV lines hanging, any foley catheters, looking at their urine.

    03:52 And again, as you notice, this is just stuff as I'm just walking in the room, and again, eyeballing and scanning my client.

    04:00 Now, here's some things to keep in mind and this is great during bedside shift report.

    04:04 If the patient's got an IV and they've got fluid running, this is a great time to verify that.

    04:10 We're gonna check the order and we're gonna make sure it's running at the correct rate.

    04:14 Now, this is a really important time to make sure you've got the right fluids hanging per the physician order and is that medication running or is that supposed to be stopped? Now, for patients on oxygen, check the liters and if the patient's even wearing their oxygen.

    04:31 Sometimes, you'll get a shift report - the patient should be wearing it, you walk in, it's sitting on their bedside.

    04:37 So, make sure you check if there's supposed to be oxygen, what liter are they at and verify the order.

    04:43 And of course, if there's any other tubes, we can check the drainage amount, what the color is and assess those - that type of equipment or drain.

    About the Lecture

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

    Included Quiz Questions

    1. The client’s level of consciousness
    2. Any signs of distress or pain
    3. The client’s current blood pressure
    4. The client’s lung sounds
    1. It establishes the client’s current status and baseline for the shift.
    2. It allows for client progress and outcomes to be evaluated.
    3. It starts when the oncoming nurse begins providing direct client care.
    4. It is conducted so that information does not have to be validated with the outgoing staff.

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

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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