Head to toe assessment complete 2024
study guide updated
when an assessment would be done beginning of each shift
weekly or monthly in long term care
whenever a change occurs
whenever you as the nurse think its necessary
what is a head to toe assessment a physical assessment of each body system that offers
objective information about the patient
the skills of assessment enable us to detect subtle as well as obvious changes in the patients
health status
to gain the patients cooperation during assessment we need to explain why it is necessary
preparing for assessment bedside reporting
look at your patients chart/computer
know their diagnosis, allergies, recent labs, HX, chief c/o
provide privacy
ensure warm comfortable temperature in room
tell patient what to expect
drape areas that dont need to be exposed
use a relaxed voice and facial expression
have a 3rd person of the patients gender present when assessing genitalia to protect yourself from
being accused of doing anything unethical
with children allow them to play with and visualize equipment prior to assessing to facilitate
cooperation
when finished ask patient if they have any questions or concerns
when asking questions don't be judgemental making sure you don't sound accusatory
ask open ended questions to foster communication
adolescents do have the right to confidentiality
elderly patients will take extra time to assess
cultural awareness need to make yourself aware of cultural differences and practices in the
population you will be working with
, Hispanics are usually very modest
Asian/ Pacific islanders avoid touching
you will have to observe and see what your patient is comfortable with
respect cultural beliefs
Setting Priorities when assessing generally we assess from head to toe direction but if a
patient presents with a specific problem or complaint we assess that area first and them when
resolved or assessed we return to the head to toe pattern
if going to do something painful save it for the last thing in that area
your going to inspect, palpate, percuss, auscultate in that order except with the abdomen
always follow infection control standards
check for latex allergies
record your assessment asap
when you assess you are gathering initial data or comparing to previous shift
an Registered nurse must do the initial admission assessment when assessing note both
your patients verbal and nonverbal cues
assessment techniquesInspection
Palpation
Percussion
Auscultation
olfaction
inspect visual exam
always pay attention watch all their movements or lack of movement
need to know normal to identify adnormals
inspect size, color, shape, and symmetry
may need your pen light to visualize
if you see something questionable ask your patient
Palpation to examine by touch
resistance, roughness, texture, temperature, mobility
do tender and painful areas last
assist the patient to relax and position comfortably arms should be at the side
palpation can be light or deep controlled by the amount of pressure applied (student nurses only
use light)
light palpation is a half inch
percussion tapping the body with fingertips to evaluate size, borders, and consistency of the
body organs
used to look for fluid in body cavities
strike the body surface with finger to create a vibration and the sound waves are heard as
percussion tones
Percussion sounds tympani
resonance
study guide updated
when an assessment would be done beginning of each shift
weekly or monthly in long term care
whenever a change occurs
whenever you as the nurse think its necessary
what is a head to toe assessment a physical assessment of each body system that offers
objective information about the patient
the skills of assessment enable us to detect subtle as well as obvious changes in the patients
health status
to gain the patients cooperation during assessment we need to explain why it is necessary
preparing for assessment bedside reporting
look at your patients chart/computer
know their diagnosis, allergies, recent labs, HX, chief c/o
provide privacy
ensure warm comfortable temperature in room
tell patient what to expect
drape areas that dont need to be exposed
use a relaxed voice and facial expression
have a 3rd person of the patients gender present when assessing genitalia to protect yourself from
being accused of doing anything unethical
with children allow them to play with and visualize equipment prior to assessing to facilitate
cooperation
when finished ask patient if they have any questions or concerns
when asking questions don't be judgemental making sure you don't sound accusatory
ask open ended questions to foster communication
adolescents do have the right to confidentiality
elderly patients will take extra time to assess
cultural awareness need to make yourself aware of cultural differences and practices in the
population you will be working with
, Hispanics are usually very modest
Asian/ Pacific islanders avoid touching
you will have to observe and see what your patient is comfortable with
respect cultural beliefs
Setting Priorities when assessing generally we assess from head to toe direction but if a
patient presents with a specific problem or complaint we assess that area first and them when
resolved or assessed we return to the head to toe pattern
if going to do something painful save it for the last thing in that area
your going to inspect, palpate, percuss, auscultate in that order except with the abdomen
always follow infection control standards
check for latex allergies
record your assessment asap
when you assess you are gathering initial data or comparing to previous shift
an Registered nurse must do the initial admission assessment when assessing note both
your patients verbal and nonverbal cues
assessment techniquesInspection
Palpation
Percussion
Auscultation
olfaction
inspect visual exam
always pay attention watch all their movements or lack of movement
need to know normal to identify adnormals
inspect size, color, shape, and symmetry
may need your pen light to visualize
if you see something questionable ask your patient
Palpation to examine by touch
resistance, roughness, texture, temperature, mobility
do tender and painful areas last
assist the patient to relax and position comfortably arms should be at the side
palpation can be light or deep controlled by the amount of pressure applied (student nurses only
use light)
light palpation is a half inch
percussion tapping the body with fingertips to evaluate size, borders, and consistency of the
body organs
used to look for fluid in body cavities
strike the body surface with finger to create a vibration and the sound waves are heard as
percussion tones
Percussion sounds tympani
resonance
