in the last module we talked about obtaining vital signs in this module we are going to continue the assessment phase of the nursing process in particularly physical assessment with looking at the head to toe Professor Hoffman and we will move on to the content again please review the reading guide for the learning objectives for this section that will identify the types of things that um could be asked on the exam the text for this section will again be the nursing skills text not the fundamentals text so in the links on the reading guide the chapters subsections are highlighted in blue they are hyperlinks that will take you straight to the readings within those sections then use the topics listed on the reading guide to focus your reading when we look at this from various steps of the head to toe assessments we'll be working off of the competency guide checklist from lab and looking at the things that we've talked about in lab as you've practiced your head to toe assessment over the last few weeks the head to toe assessment as we've been practicing in lab would be an example of an ongoing assessment it will be very similar to the assessments you'll be doing in your clinical experiences in later courses next semester you will expand on this assessment by adding a few other pieces but this will serve as the foundation for it so the first step in the nursing or in the nursing assessment there's a head to toe assessment is the preparation phase when we're looking at the rubric or the competency checklist again as I mentioned in class this will be a routine with every competency that you're involved with from here on how it involves entering the room introducing yourself again washing your hands so Hand hygiene has to happen before you have any patient contact so as soon as you walk into the room or the patient's setting uh head to the hand to the sink or to the antiseptic gel to do your hand washing you want to make sure you provide for privacy in competency check off so that will be involved closing the door to the checkoff room in the hospital setting it would be closing the door to the patient's room pulling any curtains around the bed that are available that type of thing you're going to be involved in introducing yourself by your name and also what your role is it's a patient right to know who is taking care of them so you introduce yourself by first name and the fact that your Road State nursing student and will be involved in their care you're going to identify the patient using two identifiers you're going to verify that against The Wristband of the Habit as well as against the electronic medical record which will be open on the computer you'll explain to the patient what you're going to be doing with them during this visit so it's a form of or an aspect of effective communication is letting them know what the purpose of the interaction is about in this case it's going to be the fact that you're going to be obtaining a set of vital signs and again in the check off you're going to have make sure the position is the patient is positioned comfortably sitting on the side of the bed um in the clinical setting it's just going to depend on the situation you're involved in if it's the hospital setting you may leave them resting in bed if it's an office setting they're going to be sitting in an office chair that type of thing as we move out of the preparation phase again we're doing head to toe so we're looking at a systematic approach so that we can do the same steps each time we have a patient encounter so we're going to start at the head and what we're really looking at is establishing their level of alertness their ability to communicate so looking at some really basic higher level cognitive functions or brain functions so we're going to assess their level of consciousness so we're going to look at whether they're alert or drowsy and their orientation so we're looking at orientation to person place time and situation and it's really key that we do that using open-ended questions so again rather than can you tell them your name would be please tell me your name uh where you are at what day is it uh why are you here today those types of things this would also be a time to ask um if there's any concerns they have coming into this situation or if they're having any pain when you're looking at documenting this part of this of the assessment you're going to document their level of orientation so if they've answered all the questions appropriately they would be oriented times four or oriented to person place time and situation we would identify what their abilities to verbalize is so speech is clear and appropriate and whether they expressed any discomfort so no no pain or discomfort or concerns voiced at this time those would be the normals we'd be looking for then we're going to move to the upper extremities we're going to ask them to hold their arms out towards us and using the backs of our hands we're going to filter forearms down to their wrist and their hands and what we're looking for is the skin temperature in the skin moisture we're also going to be observing for skin color and we're going to be asking so we're using again all of our senses and we're going to be asking if they're having any tingling or pain at this point then we'll also go ahead and you'll go ahead and obtain a radial pulse using the same technique that was talked about in the vital signs video and you're going to assess for the same factors that we talked about so again this phase it's going to be please hold your arms out for me thank you touch the backs of each hand so we're comparing one arm to the other and we're going to document a normal finding if it exists would be skin is warm and dry color is pink or whatever the natural skin color is a patient is able to move their upper extremities purposefully and without problem and they are not experiencing any pain or discomfort and then the pulse would be and we would give the rate whether it's regular irregular and what its amplitude was next we would move to the core of the body starting at the chest so we're going to be looking at identifying the landmarks and locations to hear the heart sounds based on the valves of the heart so please review the landmarks effect release because test questions will can involved at specific information the four valves in the heart are the aortic pulmonic tricuspid and mitral and the slide lists the locations for each of these after we've located each of the pulses and listen to them to find out which is the strongest or easiest here then you will obtain an apical pulse through auscultation and again documenting rate Rhythm and amplitude the difference between an apical pulse assessment and peripheral pulse or radial pulses that you will listen for a full minute and then record that number as your beats per minute again when we're listening to heart sounds and listening to the apical pulse we're listening for that combination love dub type sound those two sounds together are one heartbeat or one one pulse so as we're looking at the landmarks again for the various heart valves and where we can hear heart sounds I want to visualize what's happening Under the Skin so we're going to start with the second intercostal space on the patient's right side of the sternum that will be the aortic valve then directly across so in the second intercostal space on the left side of the sternum is going to be the pulmonic valve then two wire notches down on either the right or the left will be the tricuspid valve then finally in the fifth intercostal space in the mid clavicular line so straight down from the middle of the clavicle we're going to have the mitral valve so these will be the five locations that you would position your stethoscope to listen to the heart sounds and use one of those then to get your apical pulse while we're still at the Chester then we're going to start assessing the lungs uh so the things that we want to be able to do is verbalize where we're going to listen we're going to listen to four locations on the front of the chest on the anterior portion of the chest we're going to listen to One location on each side or lateral aspect of the lungs so that's going to be in line with the armpit or axilla and we're going to listen on at six locations on the posterior or back of the chest back of the thorax because we're looking at the anterior chest again visualize what's happening underneath the skin as far as the ribs we're going to visualize a line that goes across the top of the sternum at the superclavicular notch that's going to be the upper border we're going to visualize a line that's around the fifth intercostal space so basically at the level where we were listening to the mitral valve and then we're going to pick four locations two at the top and two at the bottom of that identified space those will be the four areas where we'll be listening to lung sounds for anterior lung sounds thank you next we would have the patient raise their arm which couldn't do with this picture but we're going to look at midline or at the level of the armpit or the axilla and then estimate where the bottom of the rib cage the eighth rib would be located those would be your upper and lower margins and then about halfway between or somewhere in between those two is where we would listen for a lateral lung sound we'll do this on both sides we're comparing right side to left side and again we'd be listening underneath the arm here against the skin then finally on the back we're going to draw an upper or visualize an upper boundary that is even with the base of the cervical spine so we'd have them lower their chin down and feel for the little knob at the base of the neck which would would Mark the lowest of the circle vertebrae and then we're going to identify where the base of the thoracic spine is where the tense ribs would be located and we're going to listen to six locations between those two boundaries so we're going to start at the top so we want to be close to the spine inside the scapula so we're not listening over the scapula I'm going to listen one side to the other we always want to compare one side to the corresponding part on the other lung then we're going to move about part way down roughly halfway down on each side and then at the base of that area that we had identified so again six posterior lung sounds and next we'll move to the abdomen in the abdomen we want to assess for the abdominal shape and we're going to listen for bowel sounds and in future semesters you will also be doing some palpation and possibly some percussion but right now we're looking at just visualizing and auscultating so once the individual is lying on their back we're going to visualize the abdomen in four quadrants drawing a line down through the middle then a cross-line roughly at the area of the umbilicus and then we're going to listen to four bowel sounds at each of the four quadrants a typical way of listening would be to start in the left lower quadrant or I'm sorry right lower quadrant which is where the appendix is and where the large bowel actually starts and then just sort of trace the large bowel around so we'll move up to the right upper quadrant a left upper quadrant then down to the left lower quadrant again we want to listen for at least five seconds and up to 15 seconds in each of the quadrants until we can hear some vowel sounds in our documentation at that point then will be whether they are present if they're extremely hard to hear but we can hear them by taking the full 15 seconds we may say they're hypo which means a very low activity or if they're extremely active and we hear a lot of noise we would say they are hyperactive vowel sounds so hypo normal or hyperactive for bowel sounds next we move to the lower extremities and recessing essentially the same thing here as we did for the upper extremities we're going to again with them lying on their back we're going to touch the skin from roughly the just below the knees down to the feet with the back of our hands comparing both the right leg to the left leg don't be assessing for or again temperature color and moisture and asking if they are have sensation if they can feel us touching them or if there's any discomfort when we're touching them rather than doing a pulse at this point in the lower extremities like we did in the upper extremities for this semester the only thing we're going to add at this point is to check for edema over the bones so we're going to press right above the ankle over the flat part of the tibia with our thumbs on each side and we're going to hold for a minimum of five seconds lift our thumbs and see if an indentation is present and remains or if the surface is smooth the normal would be that the surface would either be smooth or if there's a slight indentation it returns to normal within a one or two seconds that would be an indication that there is no edema if the pitting or that depression lasts longer than two seconds then we would document that edema is present on whichever of the two legs that we notice it on oh at this point on the assessment will have the patient roll to their side so they're facing away from us and again in the clinical setting they would be in a gown so you'd be able to visualize the skin surface and we're going to look at any areas of potential skin or actual skin breakdowns we're looking for pinkness or redness or actual skin damage at the points of points of contact with pressure so we'll be looking at the scapula the coccyx or tailbone and also looking at the heels those will be the primary areas we're also assessing during this process the fact or the degree to which they are independent and moving can they turn themselves easily to their side so again all of that comes into that posterior assessment at this point on the head to toe assessment we would have them sit back up at the bedside and we would obtain their blood pressure again following the same steps that we've covered in the vital signs of video the other aspect of the head to toe assessment which is on the rubric and again we'll be part of all competency checks that you do from here on out in the program is to make sure we're maintaining professionalism some aspects of professionalism is that we are in uniform have our ID on we're giving that professional appearance and again that happens in the lab in your composite checks as well as in your clinical settings later on as we're going through an assessment or a procedure with a patient it's appropriate to keep them updated on what we're seeing and what we're finding that can happen in this case while we're doing the assessment is to just verbalize to the patient what we're finding as far as lungs being clear what their vital signs were what their apical pulse was that type of thing or waiting till the end and summarizing very briefly what our overall findings were we want good hand hygiene if there is any equipment being used we want to make sure that it's clean and appropriate and in the hospital setting when we get ready to leave the room we want to make sure the patient is safe so that's going to involve things like having the bed at the lowest level having two side rails up usually it's the two upper side rails on the bed up again in an Extended Care Facility there will be no no rails up unless specifically ordered because it becomes a safety issue there or regulatory issue there but in the hospital setting we would want to embed it in the lowest position two side rails up and make sure they have their call light in reach so that's the sort of thing you would be verbalizing or demonstrating in the competency checks just as the most important thing when you walk into the room was to wash your hands after you're done um then directly contacting the patient you're going to wash your hands again and again yes uh the antiseptic gel on the wall is appropriate at this point or you could go to a sink if you're in a room that has a sink either one is a fine and then you're going to document so again when we do the competencies for this course you're just going to be documenting vital signs in your later competencies it will just depend on what the competency is so again as you're preparing for the exam just be very comfortable with what the steps are of the head to toe assessment and what it is we're assessing for and what sort of things you would document for the various various steps of the head to toe assessment the next phase will next phase or next module will be looking at the interview process as an assessment tool and looking in terms of a obtaining a patient medical history