This is Sarah with RegisteredNurseOrient.com and in this video I'm going to be performing a nursing head-to-toe assessment. This video will be similar to what you have performed in nursing school whenever you're doing your clinical checkoff. Now whenever you actually start working as a nurse you'll be able to tailor this head to toe assessment to focus on the patient's needs and you'll get a lot faster at this so what i want to do is i want to cover literally how to assess from the hair on the head all the way down to the toes so let's get started now when you're doing your head to toe assessment you follow that sequence of how you assess each system so you start out whenever you're looking at a system you're going to inspect it then palpate percuss and then auscultate except you're going to change it up a little bit whenever you're going over the abdomen you're going to inspect auscultate percuss and then palpate and the reason that you're going to auscultate second instead of last is because whenever you perform palpation percussion if you did that before it could alter the bowel sounds so we want to go ahead and just auscultate get a baseline of what we can hear and then we will percuss and palpate so first what you want to to do is you want to perform hand hygiene and provide privacy to the patient then introduce yourself to the patient and explain what you're going to be doing so hello my name is Sarah and I'm going to be your nurse today and I need to perform a head-to-toe assessment is that okay with you okay then proceed and look at their armbands so what why you're doing this is going to help you make sure you have the right patient and you're going to be testing them to see if they know who they are their date of birth and ask them some other questions to assess that neuro status. So, say your first and last name for me.
First name is Ben. Last name is Dover. Okay.
And your date of birth? 8-28-82. Okay. And do you want me to call you Ben or Mr. Dover? What do you prefer?
Ben will be fine. Okay. So, Ben, can you tell me where you're at?
I'm at the hospital. Okay. And can you tell me what we're doing here today?
Head-to-toe assessment. Okay. And who's the President of the United States? Donald Trump.
Okay. Okay. Okay. So, he answered all those correctly and he's alert and he's oriented times four. He knew who he was, he was able to tell me his name, his date of birth, where he was, what we're doing, and current events.
So we can chart alert and oriented times four. Then you'll want to collect vital signs such as the patient's heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and blood pressure. rate and the patient's pain rating. So Ben are you having any pain on a scale 0 to 10 with 0 being no pain at all and 10 being the worst pain you've ever had?
No pain, 0. Okay and I have a video on how to assess those vital signs in depth if you want to watch that video and a card should be popping up so you can access that video. Then after that what you want to do you can collect their height and their weight and look at the BMI their body mass mass index, remember if it's 18.5 or less, that's underweight, or if it's greater than 30, that is obese. Now, while you've been doing all that, asking them these questions, doing their vital signs, you're also, before you've even really assessed the system, you are already collecting information. For instance, how is that patient responding to you? What's their emotional status?
Are they calm? Are they agitated? Are they drowsy? What's going on with them? Do they look their stated age?
Does his skin color match his ethnicity? Does he understand my questions or does he seem like he can't hear them very well? Is there a delay whenever he responds to me or does he respond appropriately and at an appropriate time?
Also, do you notice any outward abnormalities like an amputation, any masses, lesions? Is his skin sweaty, cold and clammy? Do you notice any sign of...
rhinosis right off the bat. Also, is his hygiene good and is his posture good and do you notice any abnormal smells? So during all that, you're really collecting all that information. Now what we're going to do is we're going to start with the head and move our way down to the toes. So we are first going to inspect the head and we are looking at the skin color.
It's nice and pink. We're also going to make sure that the head is the same size as how it should be for the body. and it is and we're looking for any abnormal movements or twitching of the face that he can't control that are involuntary we don't see anything and we're making sure that the face is symmetrical. There's no drooping on one side like in this picture. There's drooping on one side of the face and this can be seen in Bell's palsy or in stroke.
And we're also just looking at the eyes and the ears. Are they at the same level? And while we're here we're going to go ahead and look at the facial expressions and test cranial nerve 7 which is the facial nerve.
So can you close your eyes tightly for me and open them up? okay now smile for me frown and puff out your cheeks okay and he did that with ease so that cranial nerve is intact next what we're gonna do is we're gonna pal pay the head the cranium we're gonna check for any mass masses, indentations, look for skin breakdown, any infestations. And for this part, I like to wear gloves.
So let's look at the hair. So what we're doing is we're filling for any masses, indentations, and also with this, we're looking for any skin breakdown. And if your patient's immobile, you really want to check the back of the head back here because they're laying on it a lot and there can be breakdown back there.
Also, while you're doing that, look inside the hair. Make sure there is no infestation. infestations like lice and there's no abrupt like rounding areas of baldness which could represent alopecia.
Then after that since this patient has a beard you want to check the beard as well any lesions any infestations or anything like that and just look around and then once you're done with that what you want to do is you'll doff your gloves and perform hand hygiene. Next what we're going to do is we're going to find the temporal artery and we're going to palpate them. bilaterally and they are both found right here and his are about a two plus and then while we're right there we're going to go ahead and test cranial nerve five which is the trigeminal nerve and this nerve is responsible for many things like mastication.
So what I'm going to have you do is I'm going to have you clench your teeth like bite down for me and I'm going to feel the meseter muscle which is right there it should be a nice firm ball and then feel the temporal muscle. So Now, what I'm going to do to also test that nerve is have him try to open his mouth against resistance. So try to do that for me.
Okay, and he can do that. Now while we're here, we're going to go ahead and feel the temporal mandibular joint. And we're going to feel right here and I'm going to have you open and close your mouth and I'm feeling for any grating or clicking sensations and I feel none. Then we're going to palpate the sinuses and I'm going to put pressure on these two two sinuses right here and you tell me if you feel any pain okay so the max max maxillary and the frontal no next we're moving down to the eyes and we're going to inspect the eyes first and we're looking at several things we're looking at the eyelid we're looking at the sclera which is the white of the eyes we're looking at the iris we're looking at the pupil and we're looking at the conjunctiva so you shouldn't see any swelling of the eyelids you should see that the sclera is white and shiny it shouldn't be yellow like in jaundice and the conjunctiva when you pull down the lower lid have the patient look up it should be nice and pink it shouldn't be red you shouldn't see any drainage or anything like that and look at the eyes how do they set in the eye socket is are they equal for instance as is there any strabismus is there a cross eye where one eye turns in more turns out or up or down and these eyes are normal there's no strabismus next you want to look at anisocoria where you have where one pupil would be smaller than the other people are they equal in size normal pupils should be three to five millimeters in their measurement and here his are about a three and they are equal next what we're going to do is we're going to assess some cranial nerves we're going to be looking at cranial nerve three which is ocular motor, four trochlear, and then six which is abducens.
And we're going to do several tests to check their function. The first one what we're going to do is we're going to be looking for any involuntary shaking of the eye called nystagmus. And how we're going to do that is we're going to take our pen light, we're going to hold it about 12 to 14 inches away from the patient's nose.
And Ben, what I want you to do is keep your head still, don't move your head, and just use your eyes to watch where I move the pen light. As you're doing this, you're going to perform it in the six cardinal fields of gaze. You're just going to move it and you're looking for any involuntary shaking of the eyes.
Here we go. Next we're going to see how reactive the pupils are to light. And to do that, we're going to dim the lights a little bit and we're going to have the patient stare off at a distant object that helps dilate those pupils.
And then we're going to shine using our pin light in at the side. we're going to see how that pupil responds. It should constrict. And then on the other side, it should constrict as well.
So say their baseline pupil size was like three millimeters, it should go down to one milliliter and it should happen on both sides. Okay. So Ben, stare off at that. right on the wall over there for me. Okay and that dilates the pupils and we're just going to shine light in at this side okay constrict constrict okay again then go to the other side do the same again and they both constricted in equal size next what we're going to do is we're going to check for accommodation and how we do that is we turn the lights back on we just previously had them dim but we now make it light again we're going to have him stare off at a distant object that helps dilate the pupils and we're going to take a pin light you can use a pin light finger and you're just going to slowly move it inward to the nose and what you're looking for is that those pupils constrict, they accommodate, and the eyes cross while looking at the pin line.
So here we go. Stare off in the distance please and I don't want you to move your head or anything. Just keep it real still and just follow this pin line.
Okay, ready? So now we can document because we just checked all of the things with the eyes. We can document that the pupils are equal, round, reactive to light, and accommodate. So that's where that acronym P-E-R-R. comes into play.
Next we're going to move on to the ears. So first what we do is we inspect the ears. We look on the outside of the ear. Is there any abnormalities, any redness, any drainage, anything like that. are you having any pain in your ear okay and sometimes if you have patients who've had long-term gout on the helix of the ear they may have what's called a toe five which is an accumulation of like a whitish yellowish uric acid crystal on the skin so if you ever see that that is what that looks like next we're going to palpate on the ear we're just going to move it around and being tell me if you have any tenderness whenever I do that and any feel any abnormal mass you or lesions and then move the targets a little bit does that hurt or anything like that okay so no pain or tenderness then we're going to palpate the mastoid process which is the big hump behind the ear and we're looking at it is it swollen is there any redness and whenever I touch on it being does it hurt okay and just see if the patient reports any tenderness with that then while you're there you can use the otoscope to inspect the tympanic and remember the tympanic membrane should be a pearly gray translucent color and should be shiny so for an adult you're going to pull the pin of the ear up and back and we're just going to inspect it and also while we're looking at that we are looking at the cone of light and remember the cone of light in the right ear should be at 5 o'clock and in the left ear should be at 7 o'clock next we're going to do one more thing with the ear we're going to test cranial nerve 8 which is the vestibulocochlear nerve and what i'm going to do is i'm going to include one of his ears and then whisper two words on the other side he needs to tell me what i said so you ready okay i'm gonna include this one apple banana okay very good Cat dog.
Okay, and that nerve is intact. Next, we're going to move on to the nose, and we're going to inspect the nose. We're going to make sure it's midline on the face, which it is.
We're going to look at the septum. Is it deviated? Anything like that? a patient are you having any trouble with your nose are you having any drainage or anything like that no and you want them to make you want to check the patency of the nose so then i'm going to have you occlude one side of the nostril breathe out the other and vice versa Okay, heard airflow. Airflow, nice and patent because sometimes people can have polyps that can block it or the deviated septum.
Then you want to take your pin light and you just want to look inside the nose. Look for any drainage, redness, or any like polyps or anything like that. and everything looks clear I don't see anything and then we're going to test the olfactory cranial nerve one the sense of smell so then what I'm going to have you do is I'm going to have you close your eyes and I'm going to put something in front of your nose and have you breathe in and smell and you tell me what you smell and whenever you do this use something that's pleasant smelling not something that's really stinky because it could elicit like a gag reflex or something like that if the person has a sensitive nose Okay.
Vanilla. Okay. And this was vanilla extract and that is correct. So that cranial nerve is intact. Next, we're going to move on to the mouth.
And for this part, I like to wear gloves. And if your patient is coughing and hacking, you might want to wear a mask with a shield. so you don't get any mucus on your face or in your mucus membrane so first what we're going to do we're just inspecting the lips make sure they're a nice pink color they're not chapped there's no sores on them and one thing with a lot of patients whenever their oxygen saturations are low their lips may turn dusky or blue color so you want to make sure they're nice and pink because that can represent our oxygen level now let's inspect the inside of the mouth but first let's test cranial nerve 12 which is the hypoglossal nerve and what I'm going to have you do being is I'm gonna have you stick out your tongue and move it side to side okay and he does that with ease now what we're gonna do is we're going to inspect the inside of the mouth you'll need a tongue blade for that and just open Open up your mouth for me and I want to look on the inside of the cheeks, nice and pink, don't see any sores.
You're looking to see if they're nice and pink and there's no lesions or anything like that and stick out your tongue for me. The tongue should be moist like this and pink. You don't want it to be beefy red, which is like a pernicious anemia. You don't want it to be dry or cracked.
That could be dehydration. Okay, you can put the tongue in. Then I want you to lift up your tongue for me and look for any lesions underneath the tongue.
where mouth cancer can hang out and I don't see any okay you can close then you'll while you're also looking at the gums open up a little bit you're gonna look around for cavities any loose or broken teeth no dental carries in there then okay sort of open up your mouth a little bit more put your tongue down and you're gonna look at the soft and hard palate now while you're in there you want to look at the uvula make sure it is nice in midline and his is nice and midline and we're going to test cranial nerve 9 the glossopharyngeal and so what I want to do is I'm going to have you say ah and what you want is that uvula to move up okay and then we're just going to test the gag reflex I'm sort of just going to poke a little bit back there and elicit a gag reflex okay there you go gags really good and cranial nerve 10 the vagus is intact because he's able to talk with talk to me without hoarseness and he's able to swallow Then when you're done inspecting the mouth, be sure you take off your gloves and perform hand hygiene. Now moving on to the neck. So what we're going to do is we're going to inspect the neck first. So you're going to have the patient extend the neck up a little bit and you're looking at that trachea. Is it midline?
Look for any lesions and look for any lumps like what you might see in thyroid problems like a goiter. And we don't see any of that. Then what we're going to do is we're going to test cranial nerve 11. which is the accessory nerve.
So then what I'm going to have you do is move your head side to side, up and down, okay, and then shrug, try to shrug against my resistance. And he does that with ease, so that nerve is intact. Then we're going to place him at a 45 degree angle, and we're going to have him turn his head to the side. And what we're looking at... is the jugular vein.
We're looking for any jugular vein distension, JVD. So Ben, I'm going to just turn your head to the side like that, and we're looking for any distension of the vein, and we do not see any. Next, what we're going to do is we're going to palpate.
So we're going to palpate that trachea just to confirm it is midline and Ben do you feel any tenderness or anything like that ask him if he feels any tenderness and I don't feel any lumps the next what we're going to do is we're going to palpate the lint nodes all sites of those and being as I do this tell me if you feel any tenderness and what I'm feeling for is any hard lumps or anything that may be inflamed so what we're going to do turn a little bit this way And there we go. We're going to start at the preauricular, which is right in front of the ears. Then we're going to go to the back of the ears, the postauricular. Then we're going to go to the occipital, the parotid, jugulodigastric.
Then we're going to go to the submandibular. and then the submental then we're going to go to the superficial cervical and then we're going to make our way down to the deep cervical chain any tenderness so far then we're going to go to the posterior cervical and then right above the clavicle, we're going to go to the supraclavicular and do not feel anything and no tenderness. Next, we're going to palpate the carotid artery. And this is one artery that you do not palpate bilaterally.
You do one individually. So So we're going to fill on this side and you're going to find it next to where the groove of the neck and next to the trachea and his is nice and bounding, it's 2 plus. Then we're just going to fill on the other side and same strength, 2 plus.
Then lastly what we want to do is we're going to auscultate the carotid artery and you're going to do one side at a time and you're going to compare sides and you're going to listen with the bell of your stethoscope. we're listening for a bruit which is a swishing sound. So Ben what I want to do is I'm going to have you breathe in breathe out and hold it for me okay?
Go breathe in breathe out. Breathe normally now. Did not hear it on that side okay? Breathe in breathe out for me and hold it. Okay, and I did not hear a bruit on that side as well now let's move to the upper extremities So what we're going to do is we're going to inspect the extremities and we're looking for any lesions any redness swelling and this is a good time if they have a central line and IV that you look at that make sure it's not red does IV need to be changed does that pick line or central line need a dressing change assess that then you can palpate and what we're going to do is we're going to palpate our pulse our radial artery So fill those bilaterally and they are two plus and they're equal then we're going to check capillary refill and to do that we're just going to press down on that nail bed and See how fast it comes back and it's less than two seconds Then we're going to check skin target by pinching the skin and see how fast it goes back and that was good Then we're just going to look at the right in the motion of the fingers and the hands.
Look at these joints in the hands. Do you see anything abnormal like for instance like herbedine or beauchard's nodes which are found in osteoarthritis. Ask the patient are you having any pain in your hands or anything like that?
No. Then you can palpate the brachial artery which is found in the bends of the arm and just feel those because that's another pulse site and those are two plus. Just as a side note if this was a patient that was getting dialysis and they had an AV fistula you would want to palpate that and feel for the thrill make sure that that is present up in that arm wherever their fistula is at then you want to test the muscle strength so what we're going to do is I'm going to have you squeeze my fingers as hard as you can okay okay that's really good then I'm going to have you push up against my hands and I'm going to push up against your arms okay push okay very good okay and five plus normal strength then we're just going to test his put your hand underneath the elbow and just feel as you move the arm do you feel any grating crepitus of those joints what time Sometimes in arthritis, you can feel that and move that bilaterally. Another thing you want to do with the upper extremities is to check for a drift. And what you will do is you'll have the patient hold out their arms and close their eyes, hold it up for about 10 seconds, and you're looking for a drift like this.
So go ahead, do that and close your eyes. And we're assessing to see if this hand will drift upward. And a lot of times, if a patient has had a stroke, okay, you can put them down, has had a stroke or something like that you will see a drift next we're moving on to the chest and we're going to inspect the chest we're looking for any abnormalities like lesions or any wounds anything like that we're also inspecting the patient's effort of breathing is it really labored are they using those accessory muscles to breathe also we're looking at that anterior posterior diameter so turn to the side like that and you're looking for that barrel chest and it will be increased in patients with like COPD they will have what's called the barrel chest and now what we're going to do is we're going to Listen to heart sounds and then we're going to listen to lung sounds.
So first let's auscultate heart sounds and we are going to do this in five locations and they're based on where the valves are located and I like to remember the mnemonic all patients effectively take medicine. And the first letter of each word represents the valve, except for effectively. So A would be aortic, P in patients would be pulmonic, effectively would be Erb's point.
And this is just the halfway point between the base of the heart and the apex of the heart. And there's no valve location there. And then T is for tricuspid and then M is for medicine.
So again, using the diaphragm, we're going to listen at the right of the sternal border at the second intercostal space and that's going to be the aortic valve. So to find that second intercostal space, find the sternal notch, go down to the angle of Lewis, then just go a little bit to the right and you're in the second intercostal space. And this will be the aortic and we're just listening, lub-dub, lub-dub, S1, S2, and S2, the dub is going to be louder. this location. Then we're going to go a little bit over to where the pulmonic valve is found.
That's on the left of the sternal border at the second intercostal space. So we're just right across. Again, just listening to love dub. love dub and s2 dub is going to be louder in this location then we're going to go a little bit down to the third intercostal space and this is herbs point and again you can hear love dub but there's no specific valve here then we're going to go down to the fourth intercostal space and this is where the tricuspid valve is and lub S1 is going to be the loudest at this location. Then we're going to go to the fifth intercostal space, midclavicular line, and we're going to listen to the mitral valve.
And again, S1 is going to be loudest here, dub, and there's something special about this site. This is the point of maximal impulse. This is where you're going to listen for the apical pulse. So we're going to set here and we're going to count it for one full minute and a normal apical. pulse an adult should be 60 to 100 beats per minute and his apical pulse was 63 then we're going to switch over with the bell of our stethoscope and we're just going to repeat in those locations and we're specifically listening for heart murmurs so that swishing blowing sound so that's what we're going to listen to with that And I did not hear any.
Now let's listen to lung sounds. Now when you're listening to lung sounds, you're listening for abnormal sounds. And here are some samples of some abnormal sounds that you may hear.
Crackles, wheezes, a friction rub. Or strider. First, we're going to listen anteriorly. What we're going to do is we're going to listen with the diaphragm over a stethoscope.
We're going to start at the apex of the lungs. We're going to always compare sides and just enter way downward and assess all the lobes of that right and left lung. First, let's start up here.
I want you to take a good deep breath in and out. Here we go. Apex.
Here we go. We're going to compare sides. Then we're going to move down to the second intercostal space, and this is going to help us assess the right upper lobe and the left upper lobe. So another deep breath in and out.
Then we're going to go down to the fourth intercostal space and we're going to assess where our right middle lobe is and our left upper lobe because remember the right lung has three lobes and the left lung has two lobes. So let's listen to our left upper lobe. We're just going to go down a little bit more. Then we're going to go mid axillary at the sixth intercostal space and we're going to listen to the right and left lower lobe.
So just want to turn to the side right there. Take a good deep breath in for me. Okay, other side.
Okay, now let's listen posteriorly. Again, using the diaphragm and the stethoscope, you're going to start listening at the apex and work your way down. And one thing to keep in mind when you're listening back here, you have the scapula and you don't want to listen over those because you won't.
be able to hear the sound so you're going to listen in between where the scapula and the spine are so down in these regions right here and again we're just going to compare sides and you can do this part at the end if you wanted to whenever you turn your patient over to look at their backside but we're just going to go ahead and do it now so we're going to start in the apex Compare sides. Then we're going to find C7 which is that vertebral prominence. It's the big ball right there. You can't miss it and go down to about T3 and you'll be in between the shoulder blades and go a little bit in between the shoulder blades and the spine right in there and you're going to assess the right and left upper lobes.
Then from T3 to T10, we're just going to inch around and we're going to listen to the right and left lower lobes. Okay, now we're going to assess the abdomen and remember we're switching our sequence and how we assess. We're going to do inspection, auscultation, and then percussion or palpation.
So we're going to do auscultation second. whenever you're looking and assessing the abdomen, have the patient lay on their back. And what we're going to do is we're going to inspect the abdomen. And first I want to ask Ben, are you having any stomach issues at all? No.
No. Okay. And when was your last bowel movement?
Yesterday morning. Yesterday morning and how are you urinating? Do you have any pain while you're peeing? Do you have problems starting a stream? Any discharge anything like that?
No, it's normal. Okay and with your male patients you want to ask about that due to prostate enlargement was starting a stream and if he was female I would ask him when his last menstrual period was and also again ask the female patient about urinating and things like that. Now if the patient had a Foley this is the time when you would want to look at the urine inspect the Foley and look at that just conglomerate your urinary system and your GI system together okay so we're inspecting the abdomen we're looking at the abdominal contour and this patient's is scaphoid it goes in a little bit you can also have flat rounded or protuberant and also we're going to know if there's any pulsations a lot of times in this area right here on thin patient patients like with Ben, I can see the aortic pulsation in this patient.
It's right above the umbilicus. and looking at the belly button and checking for any masses do we see any hernias or anything like that also if your patient had any wounds you would want to look at that and if they had a PEG tube you would want to assess the site make sure it's not red and ask them how it feels and with your ostomies with your ostomies you want to look at the stoma and make sure it is like a rosy pink color it's not a dusky cyanotic color and it's not prolapsed and look and see what type of stool it's putting out and note that note the smell note when if the bag needs to be changed anything like that so now we're ready to listen to the bowel sounds and what we're going to do is we're going to listen with the diaphragm of our stethoscope and we are going to start in the right lower quadrant and work our way clockwise and we're going to listen to all four quadrants and you should hear 5 to 30 sounds per minute and if you don't hear any bowel sounds you need to listen for 5 full minutes and you need to note are these normal are they hyperactive or hypoactive so let's listen this is our right lower quadrant we're going to move up to the right upper quadrant Move over to the left upper quadrant and then down to the left lower quadrant. And bowel sounds are normal. Now we're going to listen for vascular sounds. And you're going to do this with the bell of your stethoscope.
And we're going to listen at the aortic. We're going to listen at the renal arteries, iliac arteries. And you could listen at the femoral arteries if you needed to.
So you're going to listen at the aorta artery and it's a little bit below the xiphoid process a little bit above the umbilicus So about right here and we're listening for like a blowing swishing sound that which would represent a brewery Okay, and none is noted then we're going to listen at the right and left renal arteries Which is a little bit down from the aorta location. So here's the right Okay, none noted and then over the left Then we're going to listen at the iliac and it's a little bit below the belly button right here and this is the iliac artery and then listen on the other side. Again, like I pointed out you could listen at the femoral artery in the groin if you needed to now we're going to do Palpation first we're going to do light palpation then deep and being as I do this Please tell me if you feel any pain or tenderness.
So first we're going to do light palp We'll just start in the right lateral quadrant and work our way around. You're going to go about two centimeters. You're just feeling for any rigidity, any lumps, masses, anything like that.
How's that feel? It feels fine. Okay. Thank you. Okay, now we're going to do deep palpation.
And we're going to go about 4 to 5 centimeters, so a lot more deep. And again, you're just feeling for any masses, lumps. And Ben, tell me if you have any tenderness. And sometimes you can do this with two hands if need be, if you're not strong enough like me. Feeling anything?
Feels nice and soft. Heard some belly sounds. That's why you do this after you listen because you stimulate it. Okay everything felt good. Now we're going to assess the lower extremities.
So first what we're going to do is we're going to inspect. We're going to look at the color from the legs to the toes making sure it's nice and pink and here we see that Ben has a little bit of a tan line here and We're looking at the hair growth as well. You want to make sure there's normal hair growth because in PVD you will see hairless shiny thin legs and here we have excellent hair growth and Also, do you see any abnormal swelling just right off the bat? before you've even touched the patient and look at the legs and the feet for any swelling redness swelling do you have any pain or anything in your legs anything like that and looking at the joints make sure there's no redness on the joints because a lot of times with gout it likes to start out in the big toe so make sure that everything looks good and then on your diabetic patients make sure you look at the bottoms of their feet because these patients don't have the best feeling in their feet so their shoes shoes could be wearing on them or they could have stepped on something and not even know So inspect those feet, make sure there's no ulcers or anything like that that needs to be addressed.
Also, look at the toenails. Do the toenails look healthy? Or is there fungus? Are they missing toenails?
Do they have a really bad ingrown toenail? So assess for that. Next, you want to palpate your pulses. We'll palpate the palpatine pulses, which are behind the knee.
Those are about two plus they're equal bilaterally. I'm just filling his legs They're nice and warm and I'm going to push over his tibia firmly and I'm seeing if there's any edema So push there and if there is edema a lot of times whenever you push down it's like this hard like type gel it'll just separate and your finger will leave this indention and here we don't have any now we're going to palpate on the feet and we're going to feel on the pulses and I'm going to don gloves, perform hand hygiene, don gloves, and we're going to feel on the pulses in the feet. We're going to feel on the posterior tubule.
And two plus, really good. And then we're going to feel the dorsalis pedis, which is on top of the foot. 2 plus with that and if you can't ever find these because sometimes these are hard to find in patients you can get a Doppler if you have one on your floor next I'm going to check the capillary refill on his toes just like how we did with the fingers by pushing down and less than two seconds check the other one Okay, now I'm going to have him push against my hands push against my hands man Okay, good job. Now.
I'm going to have you raise your legs against resistance Good job Now we're going to check the Babinski reflex and you can use your reflex hammer for this and use the end of it or you can use your finger if you don't have that and what we're going to do is we're going to take this up through the ball of the foot and curve it and we're looking for the toes to curl in which would be a negative normal response. So let's check that. Okay.
Okay, and that was normal. Then we're gonna doff our gloves and perform hand hygiene. And next we're going to assess the back.
So whenever you're looking at the back side, you're gonna look from the head all the way down at the back and you really wanna pay attention to any abnormal moles, lesions, wounds, anything like that and assessing for skin breakdown, especially on your patient. who are mobile. So that would really be concentrating on in the backside area, on the coccyx because that's where a lot of breakdown happens and on the back of those heels if you couldn't see it whenever you were assessing the feet.
And also you could, if you hadn't already, you could listen to the lung sounds as you have the patient over on the back. Okay, so that wraps up the nursing head-to-toe assessment. Now please be sure to check out my other videos because I have a lot of... review videos to help you study for NCLEX along with other nursing skill videos career tips and everything you need to succeed in nursing school all the way to becoming a nurse in your profession so thank you so much for watching and please consider subscribing to this YouTube channel