Worried about Doing a Good Head to Toe Assessment?
I remember when I was in nursing school that I was SO
nervous about doing my head to toe assessments! The
first head to toe assessment I did, I forgot to listen to
lung sounds. Pretty embarrassing! Have any of you felt
this way as you've done your assessments?
I now work in an intensive care unit and do head to toe
assessments at least every four hours. Practice
definitely helps to make your assessment a habit! There
are so many details to keep track of.
Being able to communicate all of this information to the following nurse can be just as daunting. I
have created a report sheet found here (http://fromnewtoicu.com/nursing-basics/) on my website
www.fromnewtoicu.com under "Basics Head to Toe Assessment: Overview." Doing a thorough
assessment and giving a good report are both very important skills to develop!
What I've learned is that the best assessments are organized by body systems. Here is an example
of a head to toe assessment narrative. (Attach document here). All of this information should be
gathered during your assessment. Here's my advice for each body system and how to approach
your assessment!
Neurological: There is a HUGE variety of neurological tests that can be performed. This is my basic
testing that I do on all of my patients regardless of why they are in the hospital. If any of these are
lacking, more investigation should be done into why the patient has this deficit.
Is the patient in any kind of pain? Where and what type? Are
the patient's pupils equal, round, and reactive to light? Is the
patient alert & oriented to person (ask their name), place
(where are you?), time (ask the month and year), and
situation (do you know what brought you to the hospital?).
Can they move all extremities well? Can they squeeze your
hands tightly with both of their hands? What about applying
pressure with their feet? Is their speech clear? Do they have
any numbness or tingling?
Respiratory: Respiratory can be either a very simple or a very complicated body system to discuss.
It can be as simple as "This patient's lung sounds are clear and they are on room air. No respiratory
deficits noted." It can also be as complicated to include ventilators, chest tubes, and oscillators. For
your basic respiratory assessment, here are the questions you should be asking yourself:
Assess their lung sounds. Do they sound clear, coarse, wheezy, rhonchorous (it sounds like there is
a LOT of fluid moving around), or decreased (not much air moving)? Is their respiratory rate
normal (12-20 breaths/minute)? Are they having difficulty breathing? How much oxygen is the
patient requiring? Do they have a cough? If so, what are they coughing up? Do they have a sore
throat?
Cardiovascular: The heart can be a very complicated organ if it wants to be. There are your four
heart valves, four chambers, septums, and arteries and veins attached to complicate things even
more. The heart is also one of the most fascinating organs because of the ability it has to pump
thousands of gallons of blood through your body every day.
Here are the things to think about in your
basic cardiac assessment: Assess the patient's
heart tones. Is there a clear S1/S2 (meaning
the "lub dub" sound)? Are there any
murmurs (not a clear "lub dub" from issues
with heart valves), rubs (sounds like friction
of heart rubbing), or gallops (sounds like a
horse galloping)? What is the patient's heart
rate and rhythm? How is the patient's blood
pressure? Are they on any medications to
affect their blood pressure? How are their
radial and pedal pulses? What is their
capillary refill time? Do they have a
temperature? Are they flushed? Does the
patient have any edema? Are they wearing sequential compression devices to prevent deep venous
thrombi from forming? What IVs does the patient have? What is infusing through them?
Gastrointestinal: Isn't the GI system just our favorite? I have realized that the ICU is full of GI. Don't
sign up for my specialty unless you are ready for lots of secretions and fluids!
Assess bowel sounds. Are they present, hyperactive, hypoactive, or absent? What is the patient's
diet order? Are they having any nausea or vomiting? Do they have an nasogastric (NG) tube or
gastrostomy tube (G-tube)? If he has tube feeds infusing, what have the residuals been? (Residuals
are checked by putting a 50 mL syringe into the NG tube and pulling back whatever contents are in
the stomach.) When was their last bowel movement? What did this look like? Do they have a
colostomy or ileostomy?
Genitourinary: How much urine output a patient has tells you about a variety of different things.
The causes of low urine output could be because of acute kidney injury, low blood pressure,
infection, and ureter obstruction among other causes. If a patient's urine output has decreased,
once again ask yourself, "Why?"
Some basics in your assessment include asking the following: Does the patient have a Foley catheter
in place? If so, what is their urine output? If not, then when did they last urinate? Any pain with
urination? What does the urine look like?
Integumentary (Skin): During my assessment, I
look over the patient's skin. Are there any rashes,
bruises, or other abnormalities? The most
common places for skin abnormalities and
breakdown are shown on the picture. How is the
temperature of their skin? Do they have any
drains? What is draining and how much? Do they
have any wounds or pressure sores? What dressings are in place for these wounds?
Psychological/Social: Depending on the unit you are working on, the psychological assessment may
be very short to very in depth. If you are taking care of a suicidal or bipolar person then your
assessment will be much lengthier.
How is the patient coping with their situation? Are they calm, aggressive, anxious, combative,
frightened, etc.? How is their family coping with this situation?
Good luck to all of you as you do your head to toe assessments! Practice makes perfect! For more
information about nursing basics, check out www.fromnewtoicu.com. This has lots more
information just like this head to toe assessment post whether it be chest tubes, how to start an IV,
or how to insert an NG tube! If you are looking for a nursing program, there are also hundreds of
nursing school reviews with information about prerequisite courses, GPA requirements, tuition,
and much more! Good luck with your nursing searches!
-Courtney
From New to ICU