Head-to-Toe Assessment

(09-06-2023/ Dr. Richard McElhaney)

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Dr. McElhaney has a PhD in nursing. He was a nurse educator and the dean of nursing at the University of Mobile.

Each Head-to-Toe assessment is a little different depending on your practice.

Intro to Assessments:

- Begin the assessment when you first walk in and observe the patient

- Inspect (look), Palpate (touch), Percuss (thump), Auscultate (listen)

Vital Signs, Stats, and Neurological Indicators:

- Orientation x3. You ask people simple questions such as:

1) "What's your name?"

2) "How old are you?"

3) "What is your Date of Birth?"

4) "What is your favorite ice cream flavor?"

- Access Temperature:

1) Oral/ Mouth

2) Axillary/ Arm

3) Rectal/ Bottom

* The normal temperature isn't 98.6 that is just an average temperature

* You also can't leave the Rectal Thermometer in unsupervised

- Measure Blood pressure, Pulse, Respiratory Rate, Height & Weight, O2 Saturation:

( I got to assess Catelynn and figured out each one of these things just like a doctor would)

Head and Face:

- Check the distribution and condition of hair

- Check the scalp and bumps (palpate)

Eyes:

- Access symmetry, eyebrows, and eyelash distributions

- Check the sclera, the 6 cardinal positions of gaze, and the patient's vision

Ears:

- Inspect and palpate auricle for lesions and tenderness

- Look inside for discharge

- Tuning Fork Test (Webb's Test & Rinne Test)

- Access patients' hearing with a whisper test

Nose:

- Symmetry, check septum, inside nostrils, ask "Can you breathe through your nose?", sense of smell, palpate sinuses

Mouth and Throat:

- Moistness and color of lips, inspect teeth and gums, access buccal mucosa and palpate, examine the tongue, look at uvula and tonsil, and palpate jaw

Neck and Shoulder:

- Neck range of motion, check shoulder shrug, range of motion, palpate lymph nodes, check JVD (Jugular Vein Distinctions)

Lungs and Thorax:

- Listen to lung sounds (front and back), respiratory exclusion level, palpate thorax, access spinal curve

Circulatory System:

- Palpate carotid and temporal artery bilaterally, listen to heartbeat and heart valves

1) Aortic Valve

2) Pulmonic Valve

3) Erb's Point

4) Tricuspid Valve

5) Mitral Valve

Gastrointestinal System:

- Inspect the abdomen, listen to the 4 quadrants for "bower" sounds, palpate for pain/tenderness, ask about problems with their bowel moves or bladder

Arms and Hands:

- Sharp or dull sensation, range of motion, check skin turgor, capillary refill on fingernails

Legs and Feet:

- Motion and strength, pulse on leg and feet, access gait, sharp and dull sensations, check capillary refill on toenails

Dr. McElhaney shared a lot of information on Head-to-Toe Assessments that will become very handy. He gave great explanations on everything and I'm glad we all got to experience these and do a Head-to-Toe Assessment in class the nest day.