What does a head to toe assessment look for?

1. General Status. Vital signs. …
2. Head, Ears, Eyes, Nose, Throat. Observe color of lips and moistness. …
3. Neck. Palpate lymph nodes. …
4. Respiratory. Listen to lung sounds front and back. …
5. Cardiac. Palpate the carotid and temporal pulses bilaterally. …
6. Abdomen. Inspect abdomen. …
7. Pulses. …
8. Extremities.

A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context.

Examination of the head includes inspection of the face, skin, hair, scalp and skull. Begin by observing facial features, understanding that they may vary by sex and race. Inspect the eyebrows, eyelids, palpebral fissures, nasolabial folds and mouth, noting any asymmetry.

A focused assessment may include collecting subjective data about the patient’s diet and exercise levels, or patient’s and the patient’s family’s history of the gastrointestinal and genitourinary disease, asking about any signs of abdominal discomfort or pain, nausea, vomiting, bloating, regularity, constipation, …

1. Perform hand hygiene.
2. Check room for contact precautions.
3. Introduce yourself to patient.
4. Confirm patient ID using two patient identifiers (e.g., name and date of birth).
5. Explain process to patient.
6. Be organized and systematic in your assessment.
7. Use appropriate listening and questioning skills.

In order to effectively determine a diagnosis and treatment for a patient, nurses make four assessments: initial, focused, time-lapsed and emergency.

The nursing process functions as a systematic guide to client-centered care with 5 sequential steps. These are assessment, diagnosis, planning, implementation, and evaluation.

The nursing assessment includes gathering information concerning the patient’s individual physiological, psychological, sociological, and spiritual needs. It is the first step in the successful evaluation of a patient.

It is not hard to learn. You simply are telling the Instructor what you see by looking at someone else. You will chart what you see and what the “patient” says. So if you ask the patient if they are in pain and they admit to pain.

1. Inspect the skull and face.
2. Inspect the skin and scalp.
3. Palpate skull (especially if patient complains of tenderness or recent trauma).
4. Assess facial sensation and motor function.

Inspect the ears for discharge and note whether it is bloody or clear. Inspect the eyes for pupillary size, shape, reaction to light and movement. (See our article in the May issue on assessment of the eye.) Inspect and palpate the face for symmetry and obvious signs of trauma, and note any pain on palpation.

In which situation would the nurse most likely conduct a comprehensive assessment? A comprehensive assessment is most often performed at the beginning of a patient’s course of care, such as when a patient is newly admitted to a unit or facility.

• Inspection.
• Palpation.
• Auscultation.
• Percussion.

• Body temperature.
• Pulse rate.
• Respiration rate (rate of breathing)
• Blood pressure (Blood pressure is not considered a vital sign, but is often measured along with the vital signs.)

A comprehensive health assessment gives nurses insight into a patient’s physical status through observation, the measurement of vital signs and self-reported symptoms. It includes a medical history, a general survey and a complete physical examination.

• Patient assessment. Patient identified goals (e.g. walking 5km per day, continue living at home) …
• Planning with the patient. How can the patient achieve their goals? ( …
• Implement. …
• Monitor and review.

Assessment Phase The first step of the nursing process is assessment. During this phase, the nurse gathers information about a patient’s psychological, physiological, sociological, and spiritual status. This data can be collected in a variety of ways. Generally, nurses will conduct a patient interview.

• Initial assessment. Also called a triage, the initial assessment’s purpose is to determine the origin and nature of the problem and to use that information to prepare for the next assessment stages. …
• Focused assessment. …
• Time-lapsed assessment. …
• Emergency assessment.

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs. Shift Assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time.

WHEN YOU PERFORM a physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation. Use them in sequence—unless you’re performing an abdominal assessment. Palpation and percussion can alter bowel sounds, so you’d inspect, auscultate, percuss, then palpate an abdomen.

Examination of the neck includes inspection for any scars, masses, glandular or nodal enlargement. Inspect the trachea, noting any deviation. Next inspect the thyroid gland as the patient swallows, noting any enlargement.

The floor of the maxillary sinuses may be approached by pressing upward on the palate. Ethmoid sinuses are between the eyes and behind the nasal bridge. Palpate the area around the middle canthus to assess the ethmoids. The sphenoid sinuses are deep to the ethmoids and behind the eyes.

Careful examination of the head and neck is important because abnormalities presenting at birth in these regions are often indicative of other anomalies or a specific syndrome. Examination of the eyes and mouth requires the infant’s cooperation, and the examiner needs to be alert for opportune times.

When you visit your doctor for a routine checkup, the nurse will take you to the exam room and will typically: check your blood pressure and other vital signs. verify your health history, medications, allergies, and lifestyle choices in your electronic medical record.

A skin assessment should include an actual observation of the entire body surface, including all wounds*, inspection of hair, nails, skin folds and web spaces on hands and feet, systematically from head to toe.

Comprehensive health assessments include the patient’s history, a physical examination, and vital signs. This is used frequently during regular health visits and preventative care situations. Focused health assessments are more detailed assessments that relate to a current medical condition or patient complaint.