Head-to-toe assessment Flashcards
What is the head-to-toe assessment
- Very focused on hospital client, abbreviation assessment compared to comprehensive systems.
- Moving in head to toe fashion so we are being systematic and don’t forget anything. Not wrong if you go a different order just need to be systematic about it.
Assessment Will Depend On:
• Client’s status: acutely ill client, you will be frequently assessing, thoroughly.
• Clinical setting: med/surgical placements will be on neuro floor, you will likely to nerve/cranial testing every day.
• Standards of practice of the unit or organization: for example, in pediatrics daily weight is part of the assessment
- Nursing Judgement and Health Assessment: critical thinking process that is outlined in the nursing process, thinking what is the problem here in my assessment data. What can I do to intervene and then how do I evaluate results?
- Remember Nursing Process
- Client Well-Being and Safety: Nurses are bedside 24/7, you will develop a sense. Those feelings, intuitions that will cue you to do more assessments
Assessment and the deteriorating patient
- Patients suffer from preventable harm from our inability or failure to detect, recognize and prevent acute deterioration
- Often such critical events are preceded by hours (even days) of identifiable physiologic changes that have gone unrecognized or have not been acted upon
• Nurse concern predicts inpatient deterioration within 24 hours (nursing intuition or gut feeling).
• Nurses correctly predict patient deterioration with accuracy rates improving in nurses with > 1 year experience
Head-to-toe: before you begin
- Every client, bare minimum.
- Depending on the client will incorporate other systems assessments, or patient illness or acuity, or settings
- Perform hand hygiene
- Introduce self: by name and by role.
- Obtain necessary equipment
- Provide privacy
- Explain procedure
- Check client’s name against their armband: two unique identifiers of the client, should not be the patients room number.
- Failure to correctly identity patient continues to cause wrong medication given
Head-to-toe: general appearance
- initial impression
• Facial expression
• Body position: comfortable, guarding abdomen, struggling for breath.
• Skin colour: paleness
Head-to-toe: pain assessment
• Inquire about pain: even if they are not in for pain,
- if so PQSRSTU-AAA, and rate pain!
• If present, acquire a pain rating
Head-to-toe: quick neuro
- LOC: oriented, alert, lethargic?
- Orientation: person, place and time?
- Communication: gross communication, are answers making sense.
- Motor Response: appropriately using all four limbs as expected. Might be some functional limitations so keep that in mind.
Head-to-toe: vital signs
- TPR
- BP
- SpO2 (if required)
- Thinking about what is normal for this patient. Older patients bp is nowhere near 120/80, think about individual baselines
Head-to-toe: respiratory
Inspection (Anterior, Posterior and Lateral)
• Thoracic cage: symmetrical expansion
• Respirations: rate and rhythm (even or irregularities)
• Skin colour and condition (thinking about any oxygenation issues that may cause cyanosis)
• WOB, person’s position, facial expression
• Signs of distress (change in person’s position that looks like they are slumped over, or increased respiration rate in adults, in pediatrics nasal flaring, indrawing)
• Cough (PQRSTU-AAA) or Sputum?
Auscultation (Anterior, Posterior and Lateral)
• Assess expected breath sounds: adequate air entry, bilaterally and to bases.
• Unexpected breath sounds: maybe in the left lobe the air entry is diminished or totally decreased
• Adventitious breath sounds: crackles (fluids), wheezes (airway narrowing), strider (upper airway narrowing), pleural rub (inflammation in the lining of the lungs)
Head-to-toe: cardiovascular
Inspection
• Apical impulse: not often present in adults, but pediatric its there.
• Anterior Chest: precordium area, are you noticing any other impulses that may be unexpected.
Auscultation • Rate, rhythm (lub/dub) • Identify: • S1 (loudest at apex, bottom) • S2 (loudest at base, top) • Abnormal sounds: Am I hearing anything else besides the lub/dub
Head-to-toe: abdomen
Inspection
• Contour
• Symmetry: worried about any distension (fluid, gas, incomplete voiding)
• Umbilicus (shouldn’t be red, no lumps or bumps)
• Skin (glistening skin or tight skin would tell us ascites or fluid in the abdomen)
• Pulsations/movement; peristaltic waves or the abdominal pulsations.
• Demeanor: relaxed or guarding the abdomen
• Hair distribution: hair loss in patchy areas could because of fluid.
Auscultation
• Bowel sounds in all 4 quadrants
Palpation
• Light palpation for tenderness, rigidity
• Ask client about voiding and last bowel movement
Head-to-toe: peripheral vascular
Inspect and Palpate (Upper and Lower limbs- all 4 limbs!)
• Color (skin and nails)
• Symmetry (approximately equal)
• Temperature (Feel with back of hands), texture, turgor (pinch up flap of skin and release)
• Nails: (profile sign, clubbing, and cap refill on all four limbs)
• Peripheral pulses (radial, dorsalis pedis, posterior tibial).
- Not all of them but need at least a radial and one or two on the feet.
• Not counting the pulse rate but just checking for the pulse (pulse is present in all four limb)
• Edema
• Lesions
Head-to-toe: the hospitalized patient
- Throughout the head-to-toe assessment you should also be assessing the integument
- For patients with limited mobility and/or at risk for impaired skin integrity, BE SURE to inspect all skin surfaces affected by pressure.
- If you have someone who is not getting up and out of bed often very important you are checking their bottom of heals, sacrum etc.
- Check any tubes, wires, monitors attached to the patient, start at patient and follow it back up to where it goes.
- At IV site assess: edema, redness or tenderness, warm to touch, well secured, infiltration. In the tubing want to make sure there is no kinking, no air bubbles.
- At the pump: is it set to the right rate, at the IV bag check that it’s not empty, it’s the right solution, make sure bag and tubing is not expired.
- Catheter: Start at site, assess skin, well secured, straight, no kinks in tubing, draining well. In bag want to assess volume (measure), colour of urine, etc.
- Anything with a sticker on it (cardiovascular for example) or tapes to secure NG/nasal prongs, assess the skin underneath, rotate.
- If the patient reports a particular symptom- PQRSTUAAA
- Inspect oral cavity for patients at high risk for impaired oral hygiene: NPO, post-op, elderly, impaired neural function. Lips, tongues, mucous membrane if not being used regularly good place for skin breakdown.
- Report critical findings immediately! Let CI and nurse know right away. Vital signs out of normal range for that patient, low urine output, pain not well controlled with medications, any new bleeding, nausea, vomiting, diarrhea or change in LOC. Take priority, let someone know first before going forward.
- Leave the patient safe and comfortable with the call bell in reach
Reporting critical findings
• I-SBAR-R Communication Technique
I= identification, who is calling and who you are calling about
S= situation, why are you calling? Difficulty breathing, I’ve done a set of signs this is what they are.
B= background, 89 year old, hip reconstruction surgery, X-days post-op.
A= assessment: give most recent vital signs, what else is happening, lungs were clear now I’m hearing crackles.
R= recommendations: as you start to gain experience, for the patient I think we need to order an x-ray and do some blood work.
R= repeat, students never take verbal orders over the phone. Repeat what they told you. Confirm: you are going to be up in ten minutes and you are putting the order in now.
Documentation practice standards
Nursing documentation demonstrates:
1) Communication
• “Nurses ensure that documentation presents an accurate, clear, and comprehensive picture of the client’s needs, the nurse’s interventions and the client’s outcomes”
• everything we do should be documented so the next person knows (needs, what we’ve done, assessments, vitals)
2) Accountability
• “Nurses are accountable for ensuring their documentation of client care is accurate, timely and complete”
• timely: can’t wait to the end of the shift to document, need to do it as we go.
3) Security
• “Nurses safeguard client health information by maintaining confidentiality and acting in accordance with information retention and destruction policies and procedures that are consistent with the standard(s) and legislation”
• Want to make sure care plans don’t go home with you, need to shred it in confidentiality bin before leaving.
Assessment and infection control and prevention
- Hand hygiene
- Cleaning shared equipment: blood pressure cuffs, stethoscope, even patients who are not sick, can be infectious for a few days before showing symptoms.
- Isolate for SYMPTOMS
