Are you a nursing student that wants to cut your study time by over 60%? Well, you can head over to simplenursing.com forward slash YouTube and sign up for free. When completing your head-to-toe assessment throughout your shift, start by assessing the head.
The head assessment starts with assessing alertness and orientation to person, place, time, and situation. Start by asking the client their name, if they know where they are currently, what date or year it is, and why they are in the hospital or being seen. A normal finding is documented as AO times four. This means the client is alert and oriented to person, place, time, and situation.
Then move on to the eyes. Using a pen light, you're going to want to assess the eyes for symmetry if the pupils are equal, round, and reactive to light and accommodation, or what's known as PERLA. Now, don't forget to check the sclera and conjunctiva for abnormalities.
Next, palpate the sinuses, inspect the nares for patency, and the ability to breathe from their nose. Then inspect the mouth for abnormalities of the lips, oral mucosa, tongue, and the body. gums, and teeth. Continuing on in the head-to-toe assessment, following the head, you're going to want to assess the neck. Now, this assessment includes palpating the lymph nodes and the thyroid gland for the presence of any abnormal nodules.
You're going to want to inspect and palpate for symmetry of the trachea. Assess the ability to swallow, airway patency, and range of motion. Next, inspect for jugular venous distension, what's known as JVD.
Now, to assess the carotid arteries for the presence of any brutes. Use the bell of the stethoscope and auscultate or listen by asking the client to hold their breath and listen for any swooshing sounds over the carotids. The presence of a brute is an abnormal finding.
One of the most important areas of the assessment in the head-to-toe and one that should never be missed is the chest assessment. First, start by assessing the heart. Use the diaphragm of your stethoscope to auscultate or listen to the five areas for heart sounds. Aortic pulmonic herbs point.
tricuspid, and mitral. You're also going to want to assess the apical pulse. Now take note of any abnormalities, such as a murmur, by using the bell of your stethoscope. Now for chest and lung assessment.
Start by observing the chest for expansion. Note respiratory rate and ask about difficulty breathing or coughing. The goal in lung assessment is to compare the left side to the right side and assess for any abnormalities, like decreased or adventitious breath sounds. To do this, use the diaphragm of your stethoscope and auscultate or listen to the lungs directly.
Now, important landmarks to know are right above the clavicle to hear the apex of the lungs. The second and fourth intercostal space on both sides of the sternum and the bases are located the sixth intercostal space, mid-axillary. Now, to auscultate the lungs from the posterior thorax area, start right above the scapula to hear the apex. Then travel down midline C7 to T3 and auscultate the bases midline T3 to T10.
Now be sure to listen to our full cycle of inspiration and expiration and document any abnormalities. For abdominal assessment, remember to look, listen, then feel. So first start by inspecting the abdomen visibly for any abnormalities or distension.
Then use the diaphragm of your stethoscope and auscultate bowel sounds in all four quadrants. Auscultation should last at least one minute in each quadrant. Take note of normal, hyperactive, hypoactive, or even absent bowel sounds. Now, to document absent bowel sounds, you're going to need to listen or auscultate for three to five minutes, and if you hear nothing, that's when you document. Next, you're going to want to palpate the abdomen by placing the palmar aspect of the fingers on your dominant hand, and make sure your hands are flat.
Now, use light, gentle dipping motion and palpate for abnormalities. such as muscle guarding, rigidity, or superficial masses. Palpate clockwise, lifting your fingers as you move from one location to the other.
While performing the abdominal assessment, don't forget to inquire about bowel habits and last bowel movement. To effectively assess the extremities in a head-to-toe assessment, use these essentials. Examine the extremities for deformity, skin abnormalities, symmetry, and even edema.
Then palpate for tenderness, soft tissue swelling, and even joint effusions. Fancy words for stiff joints. Now, don't forget to assess vasculature by examining capillary refill and palpating pulses in all locations, on both arms, legs, and even the feet.
Test the range of motion for each joint in each direction. Note any abnormalities. Then check muscle strength and tone and grading strength on a scale of 0 to 5. Include any gait observations. Now, for diabetics, don't forget to thoroughly examine the toes for any ulcerations or cuts and document all findings.
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