How to Assess Your Patient from Head to Toe
Thorough patient assessments are one of the cornerstones of good healthcare. As nurses, it’s imperative that we’re comfortable giving head-to-toe assessments and aware of all essential elements involved.
With great patient care comes great responsibility. As Antonia Villarruel, PhD, RN, professor and Margaret Bond Simon Dean of Nursing at the University of Pennsylvania was quoted as saying,
“Nurses are not just doers. Our work is supported by evidence and guided by theory. We integrate evidence and theory with our knowledge of patients and make important decisions with and for patients and families at the point of care. Research and practice are not separate but integrated. Nursing is a practice discipline with our own theories and research base that we both generate, use, and disseminate to others.”
Patient assessments are an essential part of any visit because it allows various components, needs, and problems being experienced by the patient to be notated and included in the approach to comprehensive care.
But just how do we ensure that patients are getting the most optimal care? It very often starts with thorough patient assessments, of which there are two main kinds:
- Problem Focused Assessments – Problem focused assessments are completed when there is a certain body system or complaint that needs to be addressed. Questions and assessments will be related to the reason the patient is being seen.
- Complete Assessments – With complete assessments, a more head-to-toe check is completed; this type of assessment is typically conducted upon new patient set-ups, physicals, new nursing home residencies, and more.
For the purpose of this article, we’re going to dive head first into complete assessments.
Equipment and Supplies
Let’s begin with the equipment and supplies needed to perform a standard thorough head-to-toe patient assessment (subject to change based on hospital and employer or situational requirements):
- Blood pressure cuff
- Tongue depressor
- Reflex cuff
- Height measurer
The way you approach conducting your assessment should be relatively the same every time. The main patient assessment goals at this time should be:
- To establish trust
- To gain helpful background information
- To check system vitals
- To note verbal cues from the patient
- To document reported problems
- To document and note all information
Vital sign measurement is essentially checking in on the body’s basic functions for any irregularities. Obtaining accurate patient vitals is imperative to ensuring accurate, corrective, and supportive patient care can be provided in relation to where base health lies and what it’s indicating is needed. When you’re doing a head-to-toe general assessment, the list of vitals that need to be collected can be pretty long. Here’s a list of what will most likely need to be gathered (assessments needed are not limited to this list):
Check head, ear, nose, and throat for sounds, color, appearance, and functionality
- Heart rate
- Blood pressure
- Lung sounds
- Respiratory levels
- Pulse oximetry
- Check heartbeat and pulses
- Check abdomen for tenderness and bowel health
- Lymph nodes
- Range of motion (ROM)
- Respiratory rate
- Arms, legs, and feet pulses
- Check for skin lesions, bumps, abrasions, appearance, etc.
- Check gait and reflexes
Assessment Follow Up
Following the completion of a head-to-toe assessment, it’s vital that any concerns or abnormalities are reported to coordinating physicians or other healthcare providers as needed. While patient care often begins with thorough assessments, coordination amongst staff and various departments is essential to ensuring the patient receives treatment and support for continued and improved health.