Nurses how to Perform a Head to Toe Assessment
A competent nurse can perform a head to toe assessment on a patient in several minutes. It seems harder than it really is.
When you enter the room, attempt to establish eye contact with the patient. This will show you if they are alert or if this needs to be further investigated. Address them by name and introduce yourself. When they answer you, this will show you how clear their speech is and if they are oriented to self. Do their eyes meet yours or do they wander? Are they blind or hearing-impaired? This can all be determined in a few seconds.
Check pupils, mouth, nose, ears and head while you look at them and evaluate their obvious neurological status. You can do this gently and thoroughly without making them feel like a guinea pig if you take a minute or two to talk to them while you're doing it, explaining that you'll be caring for them for the next several hours and that you're getting a baseline status on them to enable you to make sure they are cared for effectively.
Talk to the patient while you check their pulse and blood pressure. You can ask them questions that will establish their orientation level, any complaints they have, and if they are in pain. While you listen to their breath sounds, you can check the skin for lesions and assess the condition of dressings. Palpate the abdomen gently and check the feet and legs while you continue to hold a conversation with them. This will enable them to stay a bit more relaxed and help you to establish a connection with them. Ask them if they feel pain when you touch them, check for the Homan's sign, and assess for edema.
Have them roll over on their side, and check their back, buttocks, and perineal area if appropriate for the situation. This will also help you tell how well they can move around in the bed.
Make sure while you are doing your assessment to ask the patient if they have any special needs during their stay. A lot of time nurses miss things simply because they don't ask the patient if they need help to the restroom, if they're hard of hearing, or if they have poor night vision. Most patients will share with you if you ask. They'll tell you they're incontinent at night or that they wear dentures or other things of importance if you'll just take a few minutes and listen to them. This is as important as your physical assessment and will leave a lasting positive impression on the people you care for during your shift.
