Woohoo! I passed my Health Assessment lab final and my Med/Surg ATI Skills Final! I have 3 more didactic finals next week so I will follow up with some tricks I used to help with those next week. I learn much of my my studying methods through trial and error so hopefully this will save you time in studying so you can perfect it even more than I!

Head-to-Toe Assessment (H2T):

Download mine here!

This is one of the primary tools ANY health care provider uses with new patients! This is different from a focused assessment, which focuses on the primary problem areas. (If you have questions about a focused review, please comment and I will touch on it further!) If you are familiar with a patient and know their PMH, it would not be efficient to constantly perform a full H2T. However, your nursing program should have some sort of exam to make sure you can do one!

Intro:

This is not listed in the H2T list. Everyone has their own way of doing things and this will change depending on the setting. Please do what but flows for you

Clinic/Outpatient Setting:

You will see in my H2T list the 8 general survey assessments listed. My professor really liked how I was able to gather information without asking awkward questions that can easily be mistaken by patients as demeaning.

  1. Upon initial contact, I walk in and reach out for a hand shake and introduce myself.
    1. Why? This will cause them to usually stand up and say their name as well
    2. I now know they have muscle coordination to shake and stand up, they have balance, they can see my hand well enough to place their hand in it, what their speech is like, and know I know they are at least A&O x1
    3. NOTE: Avoidance of handshaking, eye contact, or speech can be an indication of physics impairment OR a cultural norm (RESPECTFULLY INVESTIGATE FURTHER)
  2. “Did you find the place okay?” Did you have to drive through any traffic?”
    1. If they drove themselves/ took public trans, I now know they are A&O x4 without having to ask awkward questions!
    2. They were able to come to the right location (they know where they are) and they came on the right day and time.
      1. I hate asking if someone knows the time and day because most people (INCLUDING ME), don’t! My life is so busy I hardly remember if it is the 7th or 17th unless I am looking at a calendar! Also, not everyone has a watch! How will they know they time?!
    3. You now have A&O x 3 within a minute!
  3. As they are sitting back down, ask them what you can do for them today.
    1. If they can tell you why (ex: first-time patient H2T assessment), you now have A&O x4
    2. Also, this give you time to make your general survey (GS) assessments ninja style
  4. Ask if they are having any painful, problem areas.
    1. No? Let them know that during your assessment if they feel pain or discomfort at anytime to let you know.
    2. Yes? Save those areas for last!
  5. I NOW have your GS assessment! During this 1-2 minute intro, I have been able to observe the following:
    1. LOC/A&Ox4
    2. Age
    3. Hygiene
    4. Health (overall observable health)
    5. Physique (overweight? lean?)
    6. Posture/Gait (when they got up and walked over to shake your hand… hint: stand far enough away where they need to take some steps)
    7. Speech
    8. Sexual Development

Hospital Setting:

You should always have access to their chart. If the patient is not new, get a change of shift report and look at the chart to see what you need to focus on. Do a modified H2T based on this information, but never leave out checking:

  • How they feel? What are their goals for the day?
  • What are their questions for the MD?
  • NEW VITALS
  • Are they in pain? If so, use OLDCART or OPQRST and 0-10? What is their tolerable pain?
  • Inspect their skin, listen to GU, Cardio, and Resp. sounds, Palpate ab.
  • If they have an IV, check how it looks and flush it to assess patency
  • Last BM/urination (ask characteristics)
  • Last time they had their sheets changed and hygiene care
  • Can they/would they like to walk today? (I could go on a whole rant on how patient don’t ambulate enough in the hospital… it avoids clots, avoids lung consolidation, promotes output, etc.)

Variable**:

Anything with ** next to it means I will do it depending on the situation.

For auscultating anterior and posterior lungs, I will so 4 points in the back and 6 in the front if my patient has no history of respiratory problems, no SOB, etc. Now if while doing my points I hear something abnormal or adventitious I will go through all the points and spend extra time listening.
For the rest of the **, you should ask your lab instructor if they want it on the final. In real life, use your best judgment. If your patient had 2+, bilaterally equal radial pulses, they most likely have 2+ brachial pulses. Radial is farthest away from the body and is hardest for your body to send blood too. In an outpatient setting, your patient may have their shoes on. If they are here for an annual visit and have no pain in the BLE, then you don’t need to have them take off their shoes to get BLE pulses.

Extra Tests*:

You will learn a ton of extra tests (anything with an * on the list), but I only perform these if I have a reason. This reason being something the patient reported or if I am suspicious of a problem not reported. ALWAYS TRUST YOUR GUT! It is better to be wrong and do too much then to be right and have no done enough for you patient! Extra assessments never hurt!
I do usually like to throw in the kidney squeeze just because so many people end of having problems with their kidneys, and it is best to catch it early.
I am assuming you have some sort of background or book that goes into depth on these terms and extra tests so please refer to those. They have a TON of step-by-step illustrations that can do more for you than I can in a blog post, If you do not, comment what you are not familiar with and i will do my best to explain.