The Head to Toe Patient Assessment

Summary

This video outlines the head-to-toe assessment process in the US, emphasizing its role in establishing a patient baseline and detecting early changes. The structured approach enhances efficiency and ensures comprehensive care. It starts with assessing consciousness and orientation, followed by obtaining vital signs, including pain as the sixth vital sign. Nurses are encouraged to multitask, such as measuring blood pressure and oxygen saturation simultaneously, to complete assessments within five to ten minutes.

Key components include continuous skin assessment and detailed examinations of the head, eyes, ears, nose, mouth, neck, and thorax, identifying issues like discoloration, drainage, pressure areas, jaundice, or stroke signs. Pulmonary and cardiovascular assessments focus on accessory muscle use and abnormal breath sounds, ensuring a thorough evaluation of the patient’s condition.

Transcript

Derek and myself will be talking about and reviewing in detail, like, what a head to toe assessment here in the US, may entail. And so, Derek, do you wanna kick us off?

Yeah. Yeah. So, head to toe assessment is typically completed during the first encounter with your patient. Right? So it's a very high priority. It gives you a good benchmark for where your patient status is at, so you can compare and identify if a patient is deteriorating throughout your shift, through electronic documentation.

This also allows kind of the entire care team to see how the patient is doing, without there being, without them being there at the bedside. The head to toe assessment is a great way to help, you prioritize your patients accordingly also too throughout your shift.

Some of the members of the care team might include people like the doctor, nurse practitioner, care managers, nursing assistants, and therapists, like even respiratory or occupational.

But here in the US, we use a systematic approach to our assessments, to enhance clinical efficiency and ensure the patient's needs are met. Assessments can vary based on nursing specialty and overall patient condition as well too.

Yeah. For sure. For sure. So, like, for, like, my background being a mother baby nurse, dealing with the newborns and moms after they go through labor, You know, I would check the woman's fundus every assessment.

With Derek's, you know, background, his is more of that med surg, and so he there was be no reason for him to check a fundus. So there are differences in assessments based on specialty.

But overall, the foundation of a head to toe assessment is pretty much the same.

Great examples though, Ashton. So yeah. So now let's review the steps of a general head to toe assessment.

For the sake of time, though, we'll be kinda discussing this in relation to a stable patient, in a perfect world. Right? While assessing the patient, it is wise for the room to be well lit. This is just to ensure that nothing is missed.

The goal is to complete a full assessment typically in about five to ten minutes.

If the patient is alert and oriented, it is best, kind of practice to communicate your actions to the patient prior to the assessment and as you're navigating through it.

This can kinda ease any stress that the patient might be feeling, as they could be anxious with the unknown, especially when navigating the genitourinary system. Communication with the patient also is essential when assessing the patient's cognitive status and builds a rapport with the patient. Here's an example of a head to toe assessment for you to view as we talk about it. I do believe that there will be a link in the chat as well too, to the image so that you kinda can view it at a later date if you wish as well too.

Yeah. And so the assessment really begins right when you walk in the room. Right? You walk in. You introduce yourself to the patient, the visitors, family members, friends, whoever may be in there at the time.

And that's the really the best time to assess their level of consciousness.

Are they alert oriented? Right? Do they know who they are? Do they know where they are? Do they know why they're in the hospital? Right?

And so this is also kind of will lead you right into kind of getting their vitals. Right? Vitals include the blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, and even pain. And so, you know, here in the US during my nursing school, you know, they always taught us, you know, pain is the sixth vital sign. Right? You should always ask, you know, pain with every assessment.

And so we here in the US actually have one machine that can test and obtain all the vitals for you. And so you obviously have to hook it up, to the patient to obtain those, those vitals. But one machine can do a lot for you, and it's just a time saver. And so I'm kind of curious how many of you guys have used a machine like this, or are you guys used to doing, you know, everything manual? You know, I'm just curious. If you could put in the chat, that would be really cool.

And then, you know, again, to save you even more time, you know, doing things simultaneously.

Right? So obtaining the patient's blood pressure while you're getting the oxygen saturation level with the pulse ox. You know? Those two vital signs, you know, the patient shouldn't be speaking during. You know, and so why not get two at once. Right? So, definitely, finding some ways to save yourself time is huge and really key to get your, you know, head to toe assessments in that five to ten minute time frame.

And that comfort level will come with repetitions through this. The more you do it, the more comfortable it will become. As Ashton said, you know, some of these things will be can be done simultaneously. So, like, you can see on the diagram that the skin assessment is kind of last in the list, but just realize that you'll kind of be assessing the skin from start to finish as you move through the the checklist. You'll be looking for areas of concern, which include things like wounds or pressure areas, discoloration, temperature, and even elasticity.

This is another prime example of multiple things being assessed at once.

Yep. Absolutely. Absolutely. You know, we're all about efficiency and time saving. Right? Because you never know what's gonna pop up during your shift.

So it's always a great idea to do things, you know, multitask. Right? And so, you know, as you're going through your assessment, looking at the skin, you know, obviously, we're gonna start at the head, the top of the body. So head, eyes, ears, nose, mouth, neck.

And so for the eyes, you could look for discoloration of the sclera. Right? The yellowing, you know, is related to jaundice. So looking at that, pupil size and reactivity to light, very, very important.

The ears, looking for any drainage coming out of the ears, even skin breakdown around the ears, right, from nasal cannulas. You know, especially if it's a patient that is admitted for a while, constantly wearing a nasal cannula, they can get some breakdown, and so paying attention to that.

The nose, noticing any blockages, drainage with that.

Also skin breakdown from a nasal cannula because they sit right there. So you definitely wanna pay attention to that.

The mouth, you know, discoloration. If you see cyanosis, you know, that's obviously an oxygenation issue.

Drooping of the face as a whole, you know, that could be expected in a known stroke patient, but that could also be you identifying, like, oh, I think they are having an active stroke. Right? So paying attention to, you know, what's going on in just this small area is critical.

As far as the NET goes, you would want to look for, like, JVD. You would look for enlarged lymph nodes, the thyroid gland, you know, tracheal deviation. You know, all of those things really give you key, insight to what's going on in your patient at the time.

Yep.

And excellent points. But and, again, from the head to toe, we're gonna continue to move down the body from the head. So the next we would kinda reach is the thorax, so specifically the front and the back of the torso.

This does include the pulmonary and the cardiovascular assessments.

In a perfect world, a patient would be sitting on the edge of the bed or in a chair, but there could be situations where the patient's unable to sit like that. In those circumstances, you would just adjust the head of the bed to probably around a thirty degree angle. And then when you're ready to assess their back, you would recline the back, the bed to be flat. And that way you could roll the patient on their side, and to assess assess the back.

Right? There is an image too. So when we get to, auscultating the lungs, you will assess this kind of in an alternating pattern from, like, left to right. There are four points on the anterior side, and eight points on the back.

You will be observing for any accessory muscle use or abnormal breath sounds.

Normal breath sounds should be clear throughout all the lobes. But a key point to kinda note too is just as you're moving down, towards the bases of the lungs, those lung sounds could naturally just sound more diminished. Right? Not necessarily anything to be alarmed by, just, something just to be aware of. Right? What's normal and what's not normal. And, again, that that comfort level will come with repetition and continuing to listen and, kinda navigate this assessment.

I know there's, like, a bunch of different abnormal lung sounds, and and I just will say that, usually, like, places like YouTube are just an excellent resource to kind of, you know, give examples of those different types of lung sounds. So just something to think about if you were curious about, you know, buffing up your knowledge on those different kind of lung sounds.

Yeah. Yep. I was just gonna say, you know, looking online is such a great resource to, you know, practice and just kind of listen to if you're not used to, you know, auscultating your patients, listening to what normal sounds like and listening to what abnormal sounds like. Right?

You know, like, you know, I'm curious if you guys know, you know, the differences, like, the abnormal lung sounds. Like, what are some examples? If you can put those in the chat. Like, I'm really curious to, you know, hear if you guys, you know, have experienced patients with abnormal lung sounds.

You know?

Strider versus winging versus yeah.

Right. Yep. Exactly. Exactly.

So, you know, Derek touched on the lung, so I'll touch on the heart. And so, you know, to assess this body system, you know, you really need to not just listen to the heart, but also feel for pulses. Right?

So this allows, you know, you as the nurse to identify, you know, abnormal rates, rhythms, murmurs. Right?

And so I did find, like, a super cute little diagram to help you remember the different areas of the heart, and where to listen to them. And so this, image is basically a mnemonic device. And so there's five areas of the heart, and the mnemonic device is all people enjoy Time magazine. And so the a is for the aortic, people for the pulmonic, and joy for Herb's Pointe, time for tricuspid, and magazine for mitral.

And so, you know, this is super I mean, I just remember in nursing school, like, I would I loved these because it just made you so it made it so much easier to remember so many things. And so I'm also curious if you guys have any others that you've used or that you continue to use in your nursing practice. You know, throw those in the chat because those could also help others learning or, you know, maybe they're struggling with an area, and you could really help them. So definitely put those in there, and I think it would could be really helpful.

Excellent, Ashton. Yeah. Mnemonics and just, like, little tips and tricks for your own brain are just a huge reason to, again, just keep you on track and to keep you, aware of what you're looking for, and, make it easily attainable for you to kind of pull that, information from your own brain. Right?

Yeah. But yeah. Excellent, Ashton. We'll continue to move down. So we'll move down into the abdomen.

So as we get to the GI assessment, it should be performed in the order of inspection, auscultation, percussion, and palpation. Right? So the look, listen, and feel, this is where you can listen to the bowel sounds to ensure that there's no issues with, like, GI motility.

You will also listen to and assess all four quadrants of the abdomen.

You will be looking for any areas that might be painful to the patient also. Right? So, again, thus continuing your pain assessment as you move through the body.

After that, you will be inspecting the musculoskeletal system. So things like range of motion, strength, edema, and reflexes will kinda be the focus here to see if there's any deficiencies from the right side versus the left side, again, including your patient in the process in regards to maybe there is some weakness in their right side. And, oh, they let you know though if you're questioning that they had a stroke ten years ago, and that's just been lingering from that period of time. Or as Ashton kinda used before with this this stroke, maybe this is new, symptoms that they're experiencing, and they don't know what the, you know, what they're experiencing. But you can kinda connect those dots, for them. But another example is, like, if you notice edema in the legs, you can measure those areas by kinda, you know, pressing in with your finger, and then removing it to see if there's any pitting, and you can measure that as well too.

Yep. Absolutely. Absolutely.

And so the last and final part of the head to toe assessment will be the GU, so the genitourinary, system. And so with this being, you know, such a sensitive area, and very private, you know, it is typically, say, for the last part of the head to toe assessment. And so, again, like Derek mentioned earlier, in this, you know, in this discussion, you know, talking through your assessment. So you should be talking through it's really best practice to talk through the entire assessment.

Right? Especially if it's your patient's first time being in a hospital. Right? They don't know what's going on.

They don't they are probably terrified based like, because they're in the hospital. Right? So kind of talking them through what you're doing, can really help build that relationship with your patient, build trust, and make them just feel a little bit more comfortable. Like, you know, I can't even imagine, you know, someone just coming up to you and poking you.

Right? And you're just like, what are you doing? So it is best to kinda talk through your head to toe assessment, like, explaining what you're doing and why. That That could really, really benefit your patients, and especially during you know, when you are looking at the genital urinary system for sure.

And and that's really it. That's the general that's what a general head to toe assessment looks like. It can seem like a lot, kind of as we nav just navigated the whole thing. But just remember, like, this is a tool just to keep you on track, right, to make sure that you're getting the full picture of your patient, so that you're getting the information that's needed, as you, need to delegate care or need to prioritize the care.

Remember, this is, gonna be done during the first encounter with your patient, whether that's at the start of your shift or if the patient's kind of admitted midway through your shift and assigned to you.

So, yeah, the head to toe assessment is, critical for the whole care team as well too, and it just guides the care plan of the patient as they kind of navigate through their time in the hospital.

But, yeah, thank you guys so much for just taking this time with us, to navigate this information. We really hope it's helpful to you.

And, again, kind of as Nino said, and David too, we have an excellent clinical team here to support you guys too with any sort of questions, or issues or hurdles that you're navigating, and we do look forward to continuing conversation with you guys.

Wow. Thank you both so much. This was really this is a lot of great information, and we, there's so many things that I didn't even know. Obviously, I'm not a nurse, but, lots of new information.

And we actually got quite a few comments and questions in the chat. Oh, that's fine. And this probably won't surprise Derek and Ashton because they talk to a lot of our foreign educated nurses every day. But a lot of people commented that they are very accustomed to the manual assessments and not so much the machine that you were talking about, Ashton.

But we had a couple questions. And a couple people commented, like, in Saudi Arabia and Australia and the UK, they are using some, you know, some of maybe the monitoring machines that you're using.

Oh, awesome.

Ariel asked, is this head to toe assessment template something that can be used for all hospital, or does it depend on a hospital policy?

Yeah. Great question.

Okay. Yeah. I was just gonna say, right, this is mostly kind of a a nursing tool.

Typically, as you kinda navigate through the orientation process in a hospital, you'll be assigned with a preceptor, and they will kind of, you know, be showing you their own process for going through things. Generally speaking, though, yes, the nursing, actions, this this head to toe assessment is kinda built into our process. Right? So a veteran nurse will kinda have this all, mentally, in their brains as they kinda go through it. It won't be like a checklist on a on a clipboard that they kind of go through. But maybe early on in orientation, this is a paper document that just kinda helps keep you on track, to navigate through.

Ashton, maybe you have a little bit more kind of input on that too?

Yeah. Yeah. And so the head to toe assessment template is just kind of an example, right, of the areas that you need to hit for your initial assessment with any and all patients that you encounter.

And so, again, it's not something it's not like a form you fill out and turn in. It's just something to help guide you until, you know, you do get your routine down. You know what's expected of you. And so just an example to kind of give everyone a visual of what a head to toe assessment really entails here in the US.

And as Ashton said, there is kind of a specialty, kind of nuance to it or, some kind of differences and variations that kinda come depending on the specialty you're in. Mom baby looks different than med surg, which looks different than dialysis.

So, this is just something that we thought might be beneficial to you as you kind of prep and plan and, prepare for your, coming to the unit US.

And and, yeah, there's definitely not a downside to kind of, doing some mental, kind of homework with this and kind of, maybe just taking some, example patients from your own mental history that you can kind of, like, just navigate and kind of fill in the information for.

So the next question we have is, Ashton, you were mentioning a machine when you first started talking.

Augustine wants to know what the machine is called. Yeah. And then Felizardo asked, is it the same as a cardiac monitor? So kinda two different questions.

Yes.

Ask both about the machine.

Yes. Great question. So it is different than a cardiac monitor.

The vitals machine is kind of there's so many different brands here in the US.

So Typically, it's the vitals machine or Right.

Vitals are sick. You know what they'll call it.

So it's basically this little box that might be the size oh, man.

Of, you know, possibly, like, the screen of a laptop, we'll say.

And it's just on this literal, like, pole that's on wheels. And so you just drag it around the unit, to each patient, or some facilities may have a vitals machine hooked up to the wall and, you know, that one machine is meant for that one patient in a room. And so there's, you know, many different brands that it's really based on the hospital and the partnership that they have with companies that have medical devices. And so there's not just one brand, but definitely, it's literally called a vitals machine.

Yep. And and and, again, it will measure it it kinda it will measure the blood pressure, which you still will set up similar to the manual, but then it will read it for you. Temperature, pulse you know, the, oxygenation of the and the difference for the the telemetry box, right, the the heart rate monitor, that's different in the sense of, you know, typically, those are reserved for more of the kind of the critical care floors or the cardiac floors, and that is a separate little box that usually sits in the patient's, down pocket, and it's connected to different points in their body. And that

will kind of, send the patient's heart rate to kind of a big computer screen over at the nurses' station and we'll kind of relay what the patient's heart rate and rhythm is, where, you know, then you can kinda you know, you can have all the patients up in the nurses' station, and you can kinda keep your eye out for, you know, if if there is any abnormalities that pop up or any alarms that are gonna be going off.

Awesome. Maimuna asks how many times in p inpatients are assessed in US hospitals per shift?

Yeah. Great question. And so this will really vary based on hospital policy, the diagnosis, like, why they're in the hospital, and, also, you know, if they just got back from, you know, a surgery, if they just like, from my experience doing mother baby, you know, after the baby's delivered, you know, the mom and the baby is assessed every x amount of minutes, and then it goes to an hour, and then it goes to every two hours, then it goes to every four hours. And so, and eventually, once they are, you know, over twenty four hours out of delivery, then it's every eight hours. So it really does vary based on what's going on with your specific patient and the policy of the facility in your unit.

Yeah. And and the head to toe, especially the I feel like the biggest kind of, purpose of at least the strength for me was at the beginning of your shift. Right? Just say, hey. We're gonna get a baseline for kind of all these different systems.

After that, you know, there might be things that kind of like Ashton was saying where it's kind of more of a focused assessment. Right?

Yeah.

This might be a a neuro floor.

And so then maybe the the the checks, the frequent checks, maybe every three hours or every four hours is more maybe mainly focused on their their neuro status. Right? Is there any changes with them cognitively?

So it won't necessarily be, oh, I'm gonna be assessing the skin four times throughout my shift. No. No. No. No.

That's kinda where those differences lie. I hope that kinda answers that question for her.

Yeah. And I do wanna add, you know, there's, there's never a bad time to assess your patient. Right? If you feel like things are headed in a bad direction, you know, think your patient is just looking off, assess them. Right?

Yeah.

There is no exact time, or a bad time to assess your patient.

And to kinda that kinda sparks something in my brain because I know probably a lot of people watching are very used to paper charting. But here in the US, every mainly, majority of the time, it's gonna be computerized charting. And I will say a lot of the computerized charting is geared to especially your, like, initial documentation on geared to a layout of a head to toe.

So, again, you know, as you're collecting the data either through the head to toe, you know, assessment tool or as you're just navigating the patient through your own documentation on the computerized charting, they will kinda naturally walk through those progressions, too. So Yeah. If that's if that's helpful.

You guys are a wealth of information.

I think this I can so many I love all the feedback that our nurses are adding in the comment section.

And, I I think what I'd like to know from you guys, and I know you kind of reiterated this earlier, but I think just saying it again is important because we have so many people coming from so many different countries and different ways of doing things in their hospitals and facilities. What is the best advice you both have from now talking to and coaching so many of our nurses through their transition to practice in how they can be preparing for this? Because as you stated, Derek, and many have stated in the chat, so many are used to the manual assessments and not using computer charting. So what's kind of the best thing they can be doing right now before they arrive to the United States to help with that?

I would say a big thing once once you get stateside because, obviously, you're going through so many different transitions, and it can feel like such a it can feel so huge and maybe overwhelming.

And I just wanna, like, again, just extend you guys, just have some grace and mercy for yourselves as you navigate this space. This is a lot of information for any new nurse, that's gonna be kind of stepping into these, places. There's gonna be questions that any that any and all nurses are gonna be having, whether they're, you know, born stateside or whether they're coming in internationally.

There's gonna be so many questions that you're gonna have. And I know the biggest kinda concern will be like, oh my goodness. I don't wanna seem like I don't know what I'm doing.

But, again, you're trying to figure out your flow and your rhythm, and the only way you're gonna be able to do that is by asking questions. So maybe in your first week, you're gonna have a hundred questions, and that's gonna feel you're gonna be like, oh my goodness. But but, again, maybe a month from that point, you're gonna be kinda bringing more. So twenty questions to the table.

And then another month down the road, it's gonna be five questions. You're gonna be learning, and this information is gonna be kinda sticking. So don't feel that you're gonna have to be the perfect, have everything buttoned up and everything ready to go on day one. Oh, this is a learning process, and so do have some patience with the process and have some mercy on yourself too as you navigate it.

Okay?

That's great advice.

Have any.

Yeah. I agree. Definitely, giving yourself some grace and patience. Absolutely.

You know, and definitely just, you know, I know we supply you guys with, like, health streams and all of those things. Really, you know, take in what it's what it's sharing with you. Right?

Also getting, you know, hands on practice, where where you're at now, if you have the ability to start listening to patients. Right? Listen to their lungs. Listen to their heart.

I know in some countries, you know, that is, you know, the doctor's responsibility. And so, you know, that is something that the nurses do here. And so I think learning those sounds, whether that be through YouTube, if you can't listen to your patients. Right?

Kind of teaching yourself. Right? Really getting, you know, involved into, you know, US nursing, like, what that looks like and really learn about it. Right?

Compare it to what you're what you've been taught, what you are currently doing just so you kinda have some you know, a way to prepare yourself, you know, know what's coming.

And we heard we heard too that there is a very there's some variation in the time it takes to actually get your stateside. Right? So some of you watching might not even be working bedside right now. And so maybe it's a good time to maybe if there is positions open, you know, by you to kinda get back bedside and maybe start getting into those repetitions, into that flow again, kinda getting that knowledge brought back up to the surface. That might be really good too.

So Yep. Great point, Derek.