Nursing Assessment: Head-to-Toe vs Focused Assessment

Introduction

• Objective: Understand differences and similarities between head-to-toe and focused assessments in clinical settings.
• Importance: Students often confuse these assessment types.

Head-to-Toe Assessment

• Methodology: Follow a methodical approach from head down to toe.
  • Ensures nothing is missed.
  • Builds rapport with patients before moving to sensitive areas.
• Basic Tools: Pen light, stethoscope, PPE (personal protective equipment).
• Areas of Assessment:
  • Head:
    • Neurostatus: Ask orientation questions.
    • Mucous membranes: Check hydration status, color for signs like anemia.
  • Torso:
    • Chest: Listen to heart and lungs (anteriorly and posteriorly).
    • Back: Assess skin for pressure injuries during lung examination.
    • Abdomen: Inspect, auscultate, occasionally percuss and palpate. Check bowel movement and bladder distension.
  • Extremities:
    • Assess muscle strength and circulation (pulses and capillary refill).
    • Check pulses for equality, amplitude, and regularity.
    • Lower extremities: Check for edema. Upper extremities: Assess IV site.
  • Skin: Assess while examining other areas.

Focused Assessment

• Purpose: Assessments are more targeted depending on the specific problem a patient has.
• Common Focus Areas:
  • Neurological Problems: E.g., stroke, head injury.
    • Assess cranial nerves, cerebellar function, motor and sensory systems.
  • Cardiovascular Problems: E.g., hypertension, cardiac issues.
    • Assess all pulses, check for bruits, assess jugular venous distention (JVD).
  • Respiratory Problems: E.g., pneumonia, asthma.
    • Percussion and palpation of chest, check chest excursion.
  • Abdominal Problems: E.g., bowel obstruction, patients with feeding tubes.
    • More detailed abdominal assessment, include percussion.
  • Musculoskeletal Problems: E.g., fractures, joint replacements.
    • Assess pain, pallor, pulse, paresthesia, paralysis, and range of motion.
  • Skin Problems: E.g., burns, pressure sores, rashes.
    • Assess surgical wounds, redness, erythema, ecchymosis, drainage, and approximation.

Summary

• Routine: Always perform a head-to-toe assessment to ensure no details are missed.
• Practice: It should take less than 10 minutes with practice.
• Focused Assessment: Conduct additional assessments focusing on affected body systems.
• Resources: Demonstrations available for focused assessments on specific systems (neuro, cardiovascular, respiratory, abdomen, musculoskeletal).

Conclusion

• Combining head-to-toe and focused assessments ensures thorough patient evaluation.
• Video resources available to visualize assessment procedures.