A head to toe assessment is an integral part of being a nurse, and it provides us with significant information about how 'well' our patients are. The problem is that there are so many different ways of performing this assessment (remembering that there is no 'right' or 'wrong' way of doing this), and they can be as rudimentary or as advanced as we like. For this, I will try to keep it simple and expand on the different parts of the assessment in future posts.
P.S. This is a long read!
When you first meet your patient, remain observant and take note of their gender, age, and ethnicity. These factors can be significant predispositions for certain illness, especially in the 'at risk' population.
Gender poses a slight difficulty for the clinician, and should be dealt with delicately. Some people may have a biological (or 'birth') sex, but have a different gender. Respect should always be kept for these patients.
Take a good look at your patients expressions and non-verbal clues. Are they smiling, crying, grimacing? Are they guarding their abdomen as a sign of pain? This is type of observation a skill that requires a great deal of emotional intelligence, and practice.
Is the patient well-kept and well-groomed? Or could there be some underlying social/coping issues?
Also have a brief look at the patients size. Are they tall and lanky? Maybe they require a longer bed. Maybe they are obese, and we know that this can lead to significant illnesses. Is the patient so malnourished and thin that they could be cachectic?
Baseline observations include heart rate (HR), respiratory rate (HR), peripheral oxygen saturation (Sp02), supplemental oxygen required, blood pressure (BP), mean arterial pressure (MAP), temperature (T), level of consciousness (LOC), and a brief assessment of pain.
Airway, Breathing & Respiration:
Airway assessments begin by observing the patient. Just by inspecting you can determine if your patient appears to be cyanotic, and if they are struggling to breathe (nasal flaring, audible wheeze/stridor, sternal recession, and use of accessory muscles).
From here we can use the base line observations gathered before to undertake a throughout assessment.
Assess the rate, depth, and rhythm of the patients breathing.
Assess the patients chest expansion when breathing - is it symmetrical, asymmetrical or paradoxical? N.B. You can place your hands of the patients chest to feel for symmetry as this may be easier.
Does the patient have a cough? Undertake a history of the patients cough. Assess whether it is productive or non-productive.
Auscultate all lung fields, front and back. Is there crackling, wheezing, rhonchi, pleural rub or any other abnormal sounds? Can lung sounds be heard over both the right and left lungs? Are lung sounds decreased over the peripheral areas of the lobe?
Assess the patients supplemental oxygen requirements. Patients could be on home oxygen, or they could already have an endotracheal tube insitu. Could your patient benefit from humidified and heated high flow nasal cannula (HFNC - an education blog will be posted in the future).
In a deteriorating patient remember to assess if the trachea is midline or not. A deviated trachea can indicate a pneumothorax that requires immediate intervention.
Undertake a patient assessment by first asking if the patient gets any chest pain, and/or any noticeable palpitations. What is the patients exercise tolerance? (An education blog all about Metabolic Equivalents of Task (METs) will be posted in the future).
An assessment of circulation should begin with inspection of the extremities and lips. As with respiratory, does the patient appear pink, pale or cyanotic? Is the patient diaphoretic? Is clubbing of the finger nails evident?
Inspect for any evidence of oedema.
Palpation of the patients arteries (radial, brachial, femoral, popliteal, posterior tibial, dorsalis pedis, carotid, temporal and apical). Assess the patients capillary refill and compare results on both sides.
Auscultate the lung fields and listen for S1 & S2 (lubb and dubb). Is there presence of any abnormal sounds such as murmur, gallop or adventitious sounds?
A 12 lead ECG should be undertaken in 'high-risk' patients.
Neurological & Development:
If a patient appears unconscious then begin the neurological assessment by using the COWS acronym. Can you hear me? Open your eyes. Whats your name? Squeeze my hand.
Assess the patient using the Glasgow Coma Scale (GCS).
Inspect the patients pupils. Are they equal, and of appropriate size (not pinpoint and not blown)? Are they reactive to light? Are they round?
Does the patient have any known neurological deficit?
Take note of the patients stage of development - infancy, early childhood, preschooler, school aged, adolescence, young adult, middle adult or maturity.
Gastroenterology & Abdominal:
First being by taking a history from the patient. Ask and assess about any abdominal pain. Ask about their diet (and their appetite) and their bowel habits, have they noticed any changes? Any unexplained weight loss? Ask the patient about nausea or vomiting.
Remember the abdomen in broken up into four zones - RUQ, RLQ, LUQ & LLQ.
Inspect the abdomen - look for distention, symmetry, and marks. Is the abdomen convex, concave or flat?
Auscultate the abdomen and listen for bowel sounds.
Palpate and then percuss the abdomen for any hard areas, fluid filled or air filler regions. Does palpation cause pain?
Urine output is a big factor of the genitourinary assessment. Urine output should be around 0.5ml/kg to 1.5ml/kg.
Does the patient have an indwelling or suprapubic catheter? Is it flowing well?
Any history of discharge (purulent or blood) is important.
For men - any history of difficulty passing urine may warrant further assessment due to potential prostate issues.
Integument & Musculoskeletal:
An assessment of the patients gait can be made within the first few seconds of meeting them (provided that they mobilise). Things to look out for include limping, discomfort when walking, and the use of walking aids such as a cane, four wheeled walker, etc. All of this provides valuable information in relation to your patients wellbeing and coping ability.
Assess the patients range of motion (ROM). Check for equal strength in both arms, legs, feet and hands.
Falls risk is also important to assess, and most healthcare facilities have some type of form and procedure to formalise the falls risk assessment. Undertaking a throughout falls risks assessment involves: history of falls, current medications (over four medications, or any psychotropic medication), problems with vision or of the inner ear, age (over 65 - increased risk), cognitive impairment, and sensory changes. Falls risk assessment will allow the nurse to plan what aides the patient may require during their stay, and can help plan patient discharges back home.
Skin integrity assessment are also important, and offer key clues to patient changes. Skin integrity is an integral role of the admission process. In a ward based, a generalised skin assessment could even be conducted whilst assisting the patient with showers (to utilise time effectively). Skin integrity assessments should look for bruising, skin tears, pressure ulcers, blisters, rashes, scaring (any previous surgeries?), and any other abnormality and deformity.
As with falls risks, each hospital most likely has their own version of the waterlow risk assessment that can guide the clinician to apply extra risk-mitigation strategies to protect patients from pressure ulcers.
Undertake a quick social assessment to help understand your patient holistically.
Has anyone visited the hospital with them? Enquire about the support network that the patient has at home.
Enquire if the patient has a job, if they live in a house or apartment, and if they have any dependants.
Does the patient receive care at home?
Has anything happened in the patient life recently that may effect their coping ability?
Points to Remember:
Talk to your patient - they understand what is happening to them.
Remember which data is subjective and which is objective.
All assessments and observations should be documented - if it isn't documented then it didn't happen.
When inspecting look for symmetry, size, shape, position and colour.
All through systems assessment includes: inspection, palpation, percussion and auscultation.
Don't just assess for now, but assess for the future. Make note of any special considerations that should be taken during the patients stay.