Nursing Assessment: Head-to-Toe Physical Assessment

Introduction

• Focus on the assessment phase of the nursing process.
• Review the reading guide for learning objectives, which will aid in preparation for exams.
• Utilize the nursing skills text, not the fundamentals text.
• Head-to-toe assessment as practiced in lab is foundational for clinical experiences.

Preparation Phase

• Routine Steps:
  • Enter the room and introduce yourself.
  • Perform hand hygiene immediately upon entry.
  • Ensure patient privacy by closing doors or pulling curtains.
  • Introduce yourself, stating your name and role as a nursing student.
  • Identify the patient using two identifiers.
  • Explain the purpose of your visit.

Head-to-Toe Assessment

1. Head:

   • Evaluate level of consciousness and orientation (person, place, time, situation).
   • Use open-ended questions to assess orientation.
   • Document level of orientation, speech clarity, and any discomfort.

2. Upper Extremities:

   • Assess skin temperature, moisture, and color.
   • Check for tingling or pain.
   • Obtain radial pulse and document its characteristics.

3. Core/Chest:

   • Identify heart valve locations (aortic, pulmonic, tricuspid, mitral).
   • Obtain apical pulse through auscultation, documenting rate, rhythm, and amplitude.
   • Auscultate heart sounds (S1 & S2) using specific landmarks.

4. Lungs:

   • Listen to lung sounds in four anterior, one lateral (each side), and six posterior locations.
   • Visualize rib boundaries for accurate auscultation.

5. Abdomen:

   • Visualize in four quadrants for shape and bowel sounds.
   • Listen to bowel sounds in each quadrant, documenting as normal, hypoactive, or hyperactive.

6. Lower Extremities:

   • Similar assessment to upper extremities.
   • Check for edema by pressing above the ankles.
   • Assess for skin breakdown on pressure points (scapula, coccyx, heels).

Final Steps

• Blood Pressure:

  • Obtain and document following procedures outlined in vital signs training.

• Professionalism:

  • Maintain uniform standards with ID visible.
  • Communicate findings with the patient during or after the assessment.
  • Ensure equipment cleanliness.
  • Ensure patient safety upon leaving (bed position, call light in reach).

• Documentation:

  • Complete documentation of findings.

Conclusion

• Be comfortable with the steps and documentation required for head-to-toe assessments.
• Next module will cover the interview process and obtaining patient medical history.