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Don't you feel like a huge weight just lifted off your shoulders? This cheat sheet will walk you through the nursing assessment step-by-step. #score
So sit back and relax, my friend, because you don't need to stress about the nursing head-to-toe assessment anymore!
Print this transcript out and take it with you to clinical, skill lab, or anywhere else you need to remember the head-to-toe assessment.
Take a deep breath, and remember: you've GOT this!
YOUR HEAD TO TOE ASSESSMENT TRANSCRIPT
THE GENERAL SURVEY
Knock on the door, open the door, and provide privacy (either close the door or close the curtain)
Hello, Mrs./Mr. _____, my name is _____ and I'm a student nurse. I'll be helping out your nurse to take care of you today. Is that alright?
Great. I'm just going to wash my hands over here and then I'll just take a listen to your heart, lungs, and tummy and see how you're doing today. (Wash your hands)
While you're washing your hands, ask: Can you hear me alright? Am I talking too quietly? (This is your first test for hearing, and to make sure they can actually hear you)
I have just a few routine questions I need to ask before we get started. They'll help me take the best care of you that I can.
Can you tell me what day of the week it is? (Establishes that they are alert and oriented (A&O) to time)
Great, can you tell me where you are? (Establishes that they are alert and oriented (A&O) to place)
Wonderful. So what brought you here? (Establishes that they are alert and oriented (A&O) to the situation)
By now you will be finished washing your hands. Put on gloves. Walk over to their bed and take a look at their name bracelet.
And can you tell me your name and date of birth please? I know you've already done this a million times already, but I will check every time I come in just to make sure I'm giving you what YOU need and not someone else's. (Establishes that they are alert and oriented (A&O) to person)
CRITICAL POINT: You must use at least 2 patient identifiers to verify their identity: having them verbalize their name and birth date, as well as looking at their wrist band is the easiest.
Are you in any pain at all right now? If yes: Where does it hurt? On a scale from 1 to 10, with 1 being hardly any pain and 10 being the worst pain you've ever felt, how would you rate it? Can you describe the pain for me? Is it shooting, burning, aching, radiating, pins and needles?
Do you use anything to get around, like a walker, wheelchair, or cane?
Are you able to do things like cook, bathe, brush your hair, and brush your teeth? Or do you usually have someone help you with that?
THE PHYSICAL ASSESSMENT
Alright, thanks for answering all of my questions. I know it was a lot.
So now I'm just going to look you over a bit, see how you're doing, and listen to your heart, lungs, and tummy. I will keep you covered as much as I can, and please let me know if you have any new pain at all during this process.
Head: I'll start at your head up here.
Shine your penlight to take a look at their cheeks, gums, tongue, and throat. Note if it is red, swollen, patchy, or anything else that's not the normal "pink and moist."
Do you wear dentures? If yes: Are they uppers, lowers, or both?
Nose:
Take a look at their nose to check for symmetry.
Do you have a runny nose or are feeling stuffy at all?
I'm just going to take a quick look inside your nose.
Check for discharge, redness, or anything abnormal.
Neck:
Now I'm going to feel your neck. Please let me know if you feel any discomfort or pain.
Palpate around their neck, check for swelling, tenderness, or pain.
Can you move your head to the right for me? Now to the left? Now up, and down? Did that cause any pain or discomfort at all?
I'm going feel your collar bone here.
Gently check for skin turgor by gathering a little bit of skin between your thumb and index finger, right below their collar bone.
Arms and Fingernails:
I'm going to feel your arms now.
If your patient is a woman, ask: Have you ever had breast surgery, including a mastectomy?
If yes, ask: Which side?
CRITICAL POINT:
DON'T put a lot of pressure on that arm and DO NOT take a blood pressure on that arm. After your assessment, document in their chart that they had breast surgery on that side and follow facility policy on what to label in the room. Often times, you will put up a sign that says "No BP's on ___ side."
Gently feel their arms all the way down to their hands. Note any swelling that is present. Feel their radial pulses on both wrists, and note if the pulses are thready, weak, strong, or bounding, and if they are happening at the same time or not.
Check their fingernails for hygiene and nutrition (clean, trimmed, smooth, clear) and gently press on their fingernails to check for capillary refill.
Lungs:
Have you been coughing at all lately? If yes: Is stuff coming up when you cough? If yes: What color is it? Is it thick or thin?
I'm just going to pull down your gown a little here, I'll keep you covered as much as possible.
Inspect their chest for symmetry and shape, and note the size of their costal angle.
Now I'm going to take a listen to your lungs. I'll move my stethoscope to multiple places so that I can get a really good listen.
Each time you move your stethoscope to a new place, ask your patient: Please take a deep breath in, and out through your mouth.
Listen for a full respiratory cycle at each site. Note their breathing rhythm, effort and depth, as well as if their rib cage is moving symmetrically.
Note: Don't count the patient's respiratory rate during the lung assessment. Often times they are breathing abnormally because they are aware of their breathing. I like to check their respiratory rate during the cardiac assessment.
I'll need to listen to your lungs on your back as well. Do you need help rolling over?
Palpate down their legs. Note if their skin is intact, if there are any bruises or swelling, if their leg hair is patchy or evenly distributed, and if you can see their veins.
Do you get leg cramps? If yes: When do they happen? Is there anything that helps them go away: position changes, walking or sitting, or anything else?
Check their toenails for hygiene and nutrition (clean, trimmed, smooth, clear) and gently press on their toenails to check for capillary refill.
Feel their dorsalis pedis pulses at the same time (one on each foot) and their posterior tibialis pulses at the same time (one on each foot). Note if it is thready, weak, strong, or bounding.
Cover their legs back up.
Finishing Up:
Alrighty, we are all done. Thanks so much for your patience.
CRITICAL POINT: Make sure the bed is in the lowest position, it's locked, the rails are up or down (depending on their safety plan), and that their call light is within reach. Patient safety is always your number 1 priority!
Is there anything I can get for you?
If no: Alright. I will be back in later. You can use your call light if you need anything sooner. I'm the big red button on your call light (or whatever button it is at your facility).
Wash your hands.
**Bask in the excitement that you just totally NAILED your head to toe nursing assessment. :) **
One Final Note:
The head to toe assessment may seem scary and overwhelming at first. But the more practice you get, the more confident you will become!
While you're at clinical, seek out opportunities to do as many nursing assessments as you can. The more assessments you do, the faster you'll gain confidence!
Trust yourself. You know more than you think you do, friend.
So, walk into that room and assess your patient with confidence! You've GOT this!!
Go get 'em, tiger! Christina
LEGAL DISCLAIMER: This cheat sheet is intended for informational purposes only. This is not medical advice and errors may occur. Never treat a patient or make a nursing or medical decision based on the information provided on this cheat sheet. Never practice nursing or medicine unless you have a proper license to do so.
