Guest Author - Julie Reeser, RN
One of the best skills a nurse can possess is a firm grasp of the head to toe assessment. So many of us are working under staffing conditions that challenge our time management abilities, while we all want to do the best we can for our patients. Learning how to assess a patient as you work can be a powerful tool in beating that clock.
When you first enter a room and introduce yourself, you have already assessed the majority of the nervous system. Does the patient make eye contact, extend the proper hand to shake yours firmly or weakly, and how is their speech? During the handshake, take note of their armband. When you ask them if it is okay for you to check them over, do they attempt to assist? Do you notice neglect or difficulty with movement of a limb? While you are undoing their gown to look and listen, ask them if they are having any pain or numbness. If they are having pain, give the patient your full attention. Ask them where the pain is, how it feels, the pain scale number they would assign it, does it travel anywhere, and what relieves it or makes it worse. Be clear when you explain your plan of care for the pain.
While you are bent close to them to listen to their heart sounds, inspect their skin for JVD, color, turgor, and odor. Then, as they are breathing deeply as you auscultate the anterior lung sounds, notice if they have difficulty taking deep breaths and watch their Spo2. Ask them if they can sit up for you to listen to their back. Are they capable of doing this independently, or do they need help, or is it impossible for them to do? Can they roll slightly to one side and then the other if they are unable to sit? Encourage your patient to do the most they can for themselves to keep their muscle function and promote their sense of healing. When listening to the posterior lung sounds, keep your hand on their back. Are they warm and dry? Do they have a tremor? How is the skin on their posterior? Do they have any breakdown on the back of their head or their ears? Are they coughing? Do they seem short of breath from sitting or conversing? This is also time for you to notice their IV. Does it appear intact and functional? What is hanging in the bag and what is the rate? Look at the oxygen. Is it the ordered rate?
Have them resume a supine or sitting position, then pull their gown up to expose their abdomen. Be sure to have the sheet covering their lower half for privacy. Listen to the abdomen before palpating it. If they have a dressing, observe it for shadowing and notice what supplies you might need to change it later. If they have a drain, check it for patency and observe the color and consistency of the drainage. After you have heard bowel sounds in all four quadrants, or have waited a full minute to verify the absence of same, then ask them if they have had a bowel movement or are passing gas. Are they nauseous? Did they eat today? These questions can be asked while you are palpating the abdomen. Watch their faces as they answer you, not their belly. Do they wince? Is there guarding? If they have an AV fistula, now is a good time to ask to see it. Ask them when they had dialysis last and how it went. Notice the bruit and thrill. Be sure to observe if the room has signage to protect that arm from sticks and pressures.
Pull the gown back down, but as you do so, catch a quick glimpse at their periarea. Is it inflamed or swollen? If they have a catheter, does it appear clean? With a catheter, what does the urine look like? Do they have a cath-secure or should you add this to your list of things to bring in the room the next time through?
Explain to the patient that you are going to look at their feet. Pull the sheets up from the bottom to the mid thigh. This, again, allows the patient to feel less exposed. Check the pulses in the feet while visually inspecting the toes, soles, and shins. Ask the patient to bend their knee, one at a time, if they are able. Remind them during this time how important it is to move their legs and feet while in the bed, and tell them why so that they are part of the healing process. Lightly press on the shin area to check for edema.
If you have not visually inspected the patients buttock area, then ask them to turn on their side. Explain to them what you are doing and why. Ask them if they would like to remain on their side, propped with a pillow. Offer to rub their back for a moment. Most patients will appreciate this small kindness.
When you have finished all of this, ask the patient if there is anything they need or that you can get them at this time. This saves you time later, as you can gather these things for your next rounding.