Respond to two classmates classmate #1Head-to-Toe Assessment on a Patient
Being a core nursing skill, a thorough assessment from head to toe is key to determining the patient’s health status and actualizing adequate care. This assessment is a thorough examination of the patient, utilizing a systematic approach that starts from the head and then progresses to the toes. It aims to identify and address any abnormalities and areas of concern in the body systems. Performing a comprehensive head-to-toe assessment help the nurse to draw valid information, which supports the nurses in their clinical decision-making to choose the best options that match the patient’s needs. Below are the steps for a head-to-toe assessment:
Steps of the Head-to-Toe Assessment
The assessment often starts with gathering supplies needed for the assessment. I’ll proceed with knocking on the door while performing SWIPE, making sure that the patient is safe and free from any hazards. I’ll then introduce myself and check for the two identifiers asking the Patient their name and date of birth I’ll also ask the patient if he/she has any allergies. Next. I’ll wash my hands and explain to the Patient that I will be doing a head-to-toe assessment while providing privacy. I’ll assess the patient’s skin and obtain vitals, followed by examining facial features in the HEENT region. Head checking for any deformities, tenderness, and nodules. Then, I’ll examine the Eyes checking for PERRLA to ensure that the pupils are equal, round, reactive to light and accommodated. Ears using the whispering test or tunning fork. Nose checking to see if its midline, checking for drainage and deviated spectrum. Throat inspect enlarged lymph nodes, and the thyroid, followed by the Cardiovascular checking the heart by auscultating for lung sounds and check for the rate, rhythm and equalness of the pulses, heart auscultation, peripheral pulse palpation, and leg inspections for edema or skin discoloration.
Respiratory I will look at the mode of breathing, listen to the breath sounds using a stethoscope, and palpate for movements of the chest wall then check lung sounds making sure that they are equal on both sides. Abdominal assessment checking the four quadrants RLQ RUQ LUQ LLQ for bowel sounds, if no bowel sounds listen for an extra 5 min (Jarvis, 2023). Then proceeds to the Musculoskeletal System by inspecting range of motion of the neck, muscle strength, deformities, and symmetry. Neurological Assessment involves monitoring their awareness and touching their cranial nerves. I will check for the level of consciousness, reflexes, sensory and motor functions, and skin systems by summarizing it with the extremities. (Ernstmeyer & Christman, 2021). Overall, the integumentary part of the assessment focuses on zoning into skin, hair, and nails for any lesions, rashes, or changes.
In conclusion I will make sure the patient is safe by reversing SWIPE, putting the bed in the lowest position, putting call bell within reach and ask if the patient need anything and document the findings. A complete nursing assessment is an essential skill that nurses as healthcare providers use to collect data that unifies a patient’s health condition. Nurses can discover areas of concern or interventions through a thorough and organized strategy. Therefore, they can adequately develop a plan of care that addresses patient needs using a systematic and organized approach.
References
Ernstmeyer, K., & Christman, E. (2021). Appendix C – Head-to-Toe Assessment Checklist. Www.ncbi.nlm.nih.gov; Chippewa Valley Technical College. https://www.ncbi.nlm.nih.gov/books/NBK593191/
Jarvis, C. (2023). Physical Examination and Health Assessment E-Book. Saunders.
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classmate#2o be able to perform a complete head-to-toe assessment requires a systematic approach and the ability to describe and report findings (Jarvis, 2023). I would start by gathering the equipment I would need to perform the assessment. This equipment consists of a stethoscope and penlight. I would then prepare to enter the patient’s room by checking room precautions, their chart/past medical history, and current orders.
I would then knock and enter the patient’s room. I would perform hand hygiene upon entrance, survey the room/equipment for safety, note the position of the patient/their initial physical appearance, introduce myself, and verify the patient’s name, DOB, and MRN. I would then explain the procedure. Then I would provide privacy and inquire about any allergies and if the patient is having any pain (if the patient is having pain, I would assess what severity on a scale from 0-10).
I would start the head-to-toe assessment with the neurological system. I would check the patient’s state (alert, lethargic, obtunded, stupor, coma); ask questions to assess if patient is AOx3 (person, place, time); and use my penlight to assess for PERRLA (pupils equal, round and reactive to light and accommodation) (Jarvis, 2023).
Next, I would assess gas exchange. I would ask the patient if they have a cough and, if so, to describe it. I would observe their respiratory effort (regular/irregular, deep/shallow, even, unlabored) and get their respiratory rate. Then I would assess for lung sounds starting anteriorly using the 8 placements to listen for bronchial, bronchovesicular, and vesicular sounds noting any adventitious lung sounds (crackles, wheezes, rhonchi, stridor, etc.) Next, I would listen to lung sounds posteriorly using the 12 placements while checking the skin and sacral area for lesions, edema, redness, or signs of/risk factors for a pressure ulcer.
Following this, I would assess perfusion. I would anteriorly assess the chest, palpating the PMI for 30 seconds and obtaining the pulse rate (irregular/regular). Then I would auscultate the four valve areas for heart sounds: apical, pulmonic, tricuspid, and mitral (Fontenot, 2022). These are in the R 2nd intercostal space, L 2nd intercostal space, L 4th intercostal space, and 5th midclavicular line intercostal space. I would listen for S1 and S2, get the heart rate, and note any abnormal or extra heart sounds like S3, S4, murmurs or rubs. Following this I would check bilateral radial pulses for a 2+ pulse, check for edema, check capillary refill of <3 seconds, and check turgor for tenting beneath the clavicle. Then I would do the same but for the bilateral pedal pulses, additionally checking the patient's heels.
Next, I would assess elimination. I would ask the patient when their last bowel movement was, the color, the consistency, and if they had any diarrhea or constipation. I would ask if they had any trouble urinating, the color, and if there is any pain/odor. I would inspect the abdomen if it were flat, rounded, or scaphoid and then I would auscultate all 4 quadrants for bowel sounds in correct order: RLQ, RUQ, LUQ, LLQ. Normal bowel sounds are 5-30 every minute. Then I would palpate all 4 quadrants for tenderness, pain, firmness, or softness.
Lastly, I would check upper and lower extremity strength to finish up the neural regulation assessment. I would have the patient bilaterally squeeze my fingers, push and pull against resistance with both hands and feet, lift one leg at a time, and flex toes.
I would then make sure the patient is back in bed and positioned comfortably with the call bell in reach. I would survey the room one more time for safety, put the bed in the lowest position with 1-2 side rails up, and perform hand hygiene before leaving the room. I would then go sanitize my equipment and document/chart my findings.
References:
Fontenot, N. M., Hamlin, S. K., Hooker, S. J., Vazquez, T., & Chen, H. M. (2022). Physical assessment competencies for nurses: A quality improvement initiative. Nursing forum, 57(4), 710–716. https://doi.org/10.1111/nuf.12725
Jarvis, C. (2023). Physical Examination and Health Assessment. Elsevier.
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