Doing a head to toe assessment is something you will be doing day in and day out for the rest of your nursing career, so let’s learn how to do it quickly, and efficiently.
Doing a head to toe assessment is something you will be doing day in and day out for the rest of your nursing career, so let’s learn how to do it quickly, and efficiently.
Hello again everybody! This is Melanie, and welcome back to the Nursing School Week by Week Podcast. This is episode #5 and today we’ll be talking about the Head to Toe physical assessment. Every week I go in depth into the main topic you’ll be learning about in nursing school that week, and this time it’s the physical assessment.
Doing a head to toe assessment is something you will be doing day in and day out for the rest of your nursing career, so let’s learn how to do it quickly, and efficiently.
1st I’m going to go over some highly testable information and then I’m going to bring you along with me as I give my wonderful fiance a physical assessment.
Now, nurses complete an assessment so we can gather both subjective and objective data, make our nursing diagnoses, and then come up with a care plan. You need to know the difference between subjective data and objective data. Subjective data, are things that the patient states. I remember this because the S in Subjective goes with the S in States, for the patient states subjective data. This can be symptoms like, my head hurts, or I feel dizzy.
Objective data are things the nurse actually observes. Think O for objective goes with O for observes. Objective data are things like, the patient has a fever, or just vomited right in front of you.
Alright, so what tools do you need to do a physical assessment? You’ll need a stethoscope and a pen-light. You’ll use the stethoscope to listen to heart sounds, lung sounds, and bowel sounds. You’ll use the pen-light to check the pupils. Now, there are usually 2 sides to your stethoscope. The larger side is the diaphragm, and the smaller side is the bell. You want to use your diaphragm when you are listening to high-pitch sounds, like breath sounds, normal heart sounds, and bowel sounds. You want to use the bell when you’re listening to low-pitch sounds, like heart murmurs.
You’re going to be assessing 9 body systems. Those systems are: Neuro, HEENT (this is an acronym that stands for head, eyes, ears, nose, and throat), Cardiovascular, respiratory, gastrointestinal, genitourinary, skin, mobility, and psychosocial. And in each system, you will do things in a specific order. You’ll inspect 1st, this means you’ll look with your eyes. Then you will palpate with your hands, and then you’ll auscultate, or listen, with your stethoscope last. Now, there is one exception to this order. When you are examining the abdomen, you’ll look, then listen, and then palpate last. This is because we want to listen to undisturbed bowel sounds, and if we palpated before listening, we would be moving things around with our hands. Also, we always want to save the more painful procedure for last, and palpating could be painful if someone already has abdominal pain. Auscultating before palpating at least allows us to get that valuable information before they are in pain and refuse to cooperate any more.
Alright, so I’m gonna take you with me in just a minute so you can listen to me do a physical assessment on my fiance, but I want to do a quick podquiz so you can check your understanding.
So, the way this works is: I’m going to give you a multiple choice question, and then I’ll pause and you try to answer it.
Alright, if you answered b. The Patient has high blood pressure, then you are correct. That is an example of objective data because it’s something that you, the nurse actually saw with your own eyes. The other examples, the patient is dizzy, and in pain, or had diarrhea before coming to the hospital, those are all things the patient stated, so those would be subjective data.
Alright. Next one:
And let’s do one more:
And the correct answer is d. When listening for heart murmurs. Because heart murmurs make low-pitched sounds, and the bell of your stethoscope will pick those up a lot more clearly than the diaphragm.
Alright, if you got all three of those right, good job. If not, that’s ok. Better to get it wrong here, than on your test.
Alright, so now I’m gonna take you along with me to give my wonderful fiance a physical assessment. Hopefully he won’t be too silly.
My school doesn’t include taking vital signs as part of the physical assessment, but just assumes you’ll have already taken them, so we’re gonna assume someone’s already taken his temperature, pulse, respirations, and blood pressure.
To make your assessment as efficient as possible, you want to be inspecting the skin the whole time. You are also constantly assessing the patient’s level of consciousness and their ability to follow commands.
Alright, so I go into the patient’s room and I’m already assessing the environment. What machines do they have in the room? Is there an odd smell? What does the patient look like?
Good morning! How are you doing?
My name is Melanie, and I’m going to be your nurse today. I need to do a head to toe assessment on you. Is that alright?
I’m just going to ask you a few questions that we ask everyone who comes to the hospital.
These questions are to see if he is oriented times 4. This means does he know who he is, the place, the time, and the situation?
Can you tell me your full name? And your date of birth?
And I am checking his wrist band, to make sure I have the correct patient, and he actually knows who he is.
What month is it?
Do you know where we are?
Why are you in the hospital?
Are you in any pain right now?
Now, you generally want to work your way down the body from the head to the toes, but there’s no set in stone way that you have to do your physical assessment. If your school has a checklist it uses, then I’d go by that, but if you find that you need to tweak it a little, then go for it! Do what feels best for you. I’m going to walk you through what I like to do.
I’m going to start the physical part of the assessment now. If you feel any pain just let me know, ok?
Next I get out my pen-light
I’m going to take a look at your eyes.
Just look at the tip of my nose.
Do you wear glasses?
Then I actually look at his eyes. Before I even turn the penlight on. I’m looking at the schlera, the whites of his eyes. I’m looking for any redness, or yellow, or drainage, any cloudiness. I’m looking to see if the pupils are the same size. Then I’m going to use my penlight to check for PERRLA. That’s an acronym that stands for Pupils are Equal, Round, Reactive to Light, and Accommodation. I’m holding the penlight a little off to the side, and shining it at an angle into his eye. Both his pupils responded by constricting, or getting smaller. I do the same thing to the other eye. Now to check for Accommodation, I’ll have him look off into the distance, and then quickly adjust his eyes to something close.
Can you look at the top of the wall?
Now look at the tip of my pen.
His pupils dilated, so that shows good accommodation.
Open your mouth for me?
I’m using my penlight to look at his teeth and the sides of his mouth. I’m looking for any obvious signs of tooth decay or sores in the mouth.
Say “aahh”
I just saw the uvula, which is the dangling piece that hangs in the back of the throat move up. It should move straight up midline, without deviating to one side or the other, which it did. If it didn’t that could be a sign of a neurologic problem.
Tilt your head back, I’m just going to take a look at your nose.
I’m shining a light into his nostrils, checking for any discharge, and I’m checking the patency, which just means: Are the nostrils open.
I’m going to take a look at your ears. Can you look to the left?
I’m looking into his ears with my penlight, looking for any drainage, or sores on or behind his ears.
Do you wear a hearing aid?
Look the other way?
I put my penlight back in my pocket, because I am done with it now.
I’m going to look at your head.
I’m gently feeling around his head, and looking for any lice, or sores.
Have you had any pain or issues with your head, neck, or ears?
I’m going to listen to your heart, lungs, and belly now. I’m gonna start with your heart sounds, so just breathe normally.
I put my stethoscope on and pull his gown to the side while still maintaining his privacy as best I can. I need to get my stethoscope on bare skin. While I’m working on the chest area, I quickly pinch his skin just under the collarbone. I’m doing a turgor test to make sure he’s not dehydrated. His skin bounced back quickly, so I know he’s hydrated.
I’m going to listen for heart sounds in 4 spots. Over the aortic valve, the pulmonic valve, the tricuspid valve, and the mitral valve. A good way to remember that is with the mnemonic, “All Patients Take Medicine.” All for Aortic, Patients for pulmonic, Take for Tricuspid, and Medicine for Mitral. All Patients Take Medicine. And remember, I’m using which side of the stethoscope to listen for normal heart sounds? That’s right, the diaphragm.
Now I’m going to listen to your lung sounds. Take a deep breath when you feel my scope.
I’m listening to 10 spots on his anterior side. It’s kinda hard for me to describe where I’m putting the scope, but I’ll post some pictures on the website, Nursing School Week by Week.com and you can go there to see exactly where I’m placing the scope on his front and then back.
Alright, if you can lean forward for me, I’m going to listen to your lungs in the back. Take a deep breath when you feel my scope.
I’m listening to his breath sounds in 8 different spots on his back. Some abnormal breath sounds that I’m listening for are crackles, which sound like this:
A wheeze which sounds like this:
Or a stridor which sounds like this:
You can sit back again.
I’m going to listen to your belly.
I’m placing my stethoscope in each of the 4 quadrants of his abdomen and listening until I hear a gurgling sound. If I hear 5-30 sounds within a minute, I can report that his bowel sounds are “normoactive”. Less than 5 sounds in a minute would be hypoactive. More than 30 would be hyperactive. If I didn’t hear any sounds, I would have to listen for a full 5 minutes in each quadrant before I could report that the bowel sounds are absent. And I really hope that doesn’t happen, because that would be really awkward to just be down there with my stethoscope for 20 minutes!
I take my stethoscope off, because I’m done with it.
I’m going to palpate your belly. Do you feel any pain?
Now I’m going to assess his arms and hands.
I cross my arms and hold out two fingers on each hand.
Can you squeeze my fingers?
Now pull me towards you?
Sometimes you may get a patient who thinks it’s funny to try to pull you down on top of him. This is why you cross your arms first, to make it easier to break the hold quickly if you need to.
I’m going to look at your fingernails.
I am looking for any discoloration of the nails, and I take this time to squeeze the thumb nails to check the capillary refill time. The nails will turn white when I squeeze them, but should return to their normal color within 3 seconds.
I’m going to check your pulse.
I’m feeling his radial pulse bilaterally, that means I’m feeling it on both wrists at the same time. It feels regular, and 2+, which is normal.
Can you hold your arms out to the side?
And straight up?
I’m assessing his range of motion.
Any pain when you do those movements?
I’m going to look at your feet?
If he had socks on, I would take them off.
I’m checking his pedal pulse bilaterally, both feet at the same time.
I’m also squeezing his big toes to check for capillary refill, just like I did on his thumbs.
Can you lift your right leg up to my hand?
And your left?
Can you bend your legs?
Can you turn away from me?
I’m just taking a look at your skin.
The sacral area, on the tailbone is a common spot to see pressure ulcers, so I’m checking for any skin breakdown in that area.
Have you had any pain or burning during urination?
Alright, well, that’s all I need right now.
Is there anything I can get for you now?
Here’s your call light. Let me know if you need anything.
Alright, so that’s how I do my head to toe physical assessment. Real quick, I have one more quiz question for you:
When assessing the pupils, what does the A in the acronym PERRLA stand for?
If you answered c. Accommodation, then you are correct. Remember, this is when you have the patient look at something in the distance, and then quickly look at something close, like the tip of your pen. When they do that, their pupils should constrict. That is called accommodation.
Okay! I hope this podcast helped give you an idea of what a physical assessment looks like. If you found this helpful, please leave a review on Apple Podcast, so I know you guys are out there and listening. Have a great week, and I will talk to you soon!