Head To Toe Assesment

Worried about Doing a Good Head to Toe Assessment?
I remember when I was in nursing school that I

was SO nervous about doing my head to toe
assessments! The first head to toe assessment
did, I forgot to listen to lung sounds. Pretty
embarrassing! Have any of you felt this way as
you've done your assessments?
I now work in an intensive care unit and do

head to toe assessments at least every four
hours. Practice definitely helps to make your
assessment a habit! There are so many details
to keep track of.
Being able to communicate all of this information to the following nurse can be just
as daunting. I have created a report sheet found here
(http://fromnewtoicu.com/nursing-basics/) on my website www.fromnewtoicu.com
under "Basics Head to Toe Assessment: Overview." Doing a thorough assessment
and giving a good report are both very important skills to develop!
What I've learned is that the best assessments are organized by body systems. Here
is an example of a head to toe assessment narrative. (Attach document here). All of
this information should be gathered during your assessment. Here's my advice for
each body system and how to approach your assessment!
Neurological: There is a HUGE variety of neurological tests that can be performed.
This is my basic testing that I do on all of my patients regardless of why they are in
the hospital. If any of these are lacking, more investigation should be done into why
the patient has this deficit.
Is the patient in any kind of pain? Where and what

type? Are the patient's pupils equal, round, and
reactive to light? Is the patient alert & oriented to
person (ask their name), place (where are you?),
time (ask the month and year), and situation (do
you know what brought you to the hospital?). Can
they move all extremities well? Can they squeeze
your hands tightly with both of their hands? What
about applying pressure with their feet? Is their speech clear? Do they have any
numbness or tingling?
Respiratory: Respiratory can be either a very simple or a very complicated body

system to discuss. It can be as simple as "This patient's lung sounds are clear and
they are on room air. No respiratory deficits noted." It can also be as complicated to
include ventilators, chest tubes, and oscillators. For your basic respiratory
assessment, here are the questions you should be asking yourself:
Assess their lung sounds. Do they sound clear, coarse, wheezy, rhonchorous (it
sounds like there is a LOT of fluid moving around), or decreased (not much air
moving)? Is their respiratory rate normal (12-20 breaths/minute)? Are they having
difficulty breathing? How much oxygen is the patient requiring? Do they have a
cough? If so, what are they coughing up? Do they have a sore throat?
Cardiovascular: The heart can be a very complicated organ if it wants to be. There
are your four heart valves, four chambers, septums, and arteries and veins attached
to complicate things even more. The heart is also one of the most fascinating
organs because of the ability it has to pump thousands of gallons of blood through
your body every day.
Here are the things to think about in

your basic cardiac assessment: Assess
the patient's heart tones. Is there a
clear S1/S2 (meaning the "lub dub"
sound)? Are there any murmurs (not a
clear "lub dub" from issues with heart
valves), rubs (sounds like friction of
heart rubbing), or gallops (sounds like
a horse galloping)? What is the
patient's heart rate and rhythm? How
is the patient's blood pressure? Are
they on any medications to affect their
blood pressure? How are their radial and pedal pulses? What is their capillary refill
time? Do they have a temperature? Are they flushed? Does the patient have any
edema? Are they wearing sequential compression devices to prevent deep venous
thrombi from forming? What IVs does the patient have? What is infusing through
them?
Gastrointestinal: Isn't the GI system just our favorite? I have realized that the ICU is
full of GI. Don't sign up for my specialty unless you are ready for lots of secretions
and fluids!
Assess bowel sounds. Are they present, hyperactive, hypoactive, or absent? What is
the patient's diet order? Are they having any nausea or vomiting? Do they have an
nasogastric (NG) tube or gastrostomy tube (G-tube)? If he has tube feeds infusing,
what have the residuals been? (Residuals are checked by putting a 50 mL syringe
into the NG tube and pulling back whatever contents are in the stomach.) When was
their last bowel movement? What did this look like? Do they have a colostomy or
ileostomy?
Genitourinary: How much urine output a patient has tells you about a variety of
different things. The causes of low urine output could be because of acute kidney
injury, low blood pressure, infection, and ureter obstruction among other causes. If a
patient's urine output has decreased, once again ask yourself, "Why?"
Some basics in your assessment include asking the following: Does the patient have
a Foley catheter in place? If so, what is their urine output? If not, then when did they
last urinate? Any pain with urination? What does the urine look like?
Integumentary (Skin): During my
assessment, I look over the patient's skin.
Are there any rashes, bruises, or other
abnormalities? The most common places
for skin abnormalities and breakdown are
shown on the picture. How is the
temperature of their skin? Do they have any drains? What is draining and how
much? Do they have any wounds or pressure sores? What dressings are in place for
these wounds?
Psychological/Social: Depending on the unit you are working on, the psychological
assessment may be very short to very in depth. If you are taking care of a suicidal
or bipolar person then your assessment will be much lengthier.
How is the patient coping with their situation? Are they calm, aggressive, anxious,
combative, frightened, etc.? How is their family coping with this situation?
Good luck to all of you as you do your head to toe assessments! Practice makes
perfect! For more information about nursing basics, check out
www.fromnewtoicu.com. This has lots more information just like this head to toe
assessment post whether it be chest tubes, how to start an IV, or how to insert an
NG tube! If you are looking for a nursing program, there are also hundreds of
nursing school reviews with information about prerequisite courses, GPA
requirements, tuition, and much more! Good luck with your nursing searches!
-Courtney
From New to ICU

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Worried about Doing a Good Head to Toe Assessment?

I remember when I was in nursing school that I

I now work in an intensive care unit and do

Is the patient in any kind of pain? Where and what

Respiratory: Respiratory can be either a very simple or a very complicated body

Here are the things to think about in

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