# Head-to-Toe Nursing Assessment: Step-by-Step 🩺 **Channel:** Lecturio Nursing **Source:** https://www.youtube.com/watch?v=CxvZOGZ6ZII **Transcript page:** https://www.withtranscript.ai/video/CxvZOGZ6ZII ## Chapters - 0:00 — Introduction to Initial Patient Assessment - 1:10 — Vital Signs, History, and Respiratory Check - 5:31 — Abdominal Assessment and Elimination Review - 7:23 — Extremity Circulation, Strength, and Sensation - 10:42 — Closing Checks and Safety Measures ## Transcript **[0:00] Speaker A:** Hello, I'm Professor Ray. And in nursing school, you'll likely have to demonstrate a head-to-toe patient assessment for a grade. But more importantly, you'll do a basic patient assessment at the beginning of each shift or the first time you see a patient. Now, there are several ways to do an effective patient assessment, but today, I'm going to show you the order and flow I like to use in my practice and have found to be the most efficient. Your initial assessment is meant to identify anything that needs a deeper assessment and to follow up on the reason for the patient's visit. In this video, I will talk to the patient and give you tips and strategies on how you can perform a similar exam. This initial exam should take you about 10 minutes after you practice this important skill. Knock knock. **[0:51] Speaker B:** Hi. **[0:52] Speaker A:** Hi, I'm Samantha. I'm going to be your nurse today. **[0:55] Speaker B:** Okay. **[0:55] Speaker A:** Can you tell me your name and date of birth, please? **[0:58] Speaker B:** Brandon Smith, March 7th, 1996. **[1:00] Speaker A:** Okay, perfect. Can you tell me what month and also what day of the week it is? **[1:05] Speaker B:** Uh September and it's Tuesday. **[1:07] Speaker A:** Perfect. And also where you're at today? **[1:09] Speaker B:** The hospital. **[1:09] Speaker A:** Okay, great. **[1:10] Speaker A:** So, when I walked into the room, I can already see that Brandon's awake, he's alert, his eyes were tracking me as well, and also he's answering appropriately. Now next, Brandon, I'd like to ask you, do you have any allergies? **[1:22] Speaker B:** No. **[1:23] Speaker A:** Okay, perfect. So, this would be a great time to go ahead and get a full set of vital signs. That's going to give us a really good indicator of his hemodynamic status, so I get a blood pressure, a heart rate, a respiratory rate, and oxygen saturation as well as a temp. Now, if any of those are critical or abnormal, we want to make sure we report those. Now next, Brandon, I would like to ask you, do you have any pain anywhere? **[1:47] Speaker B:** No. **[1:48] Speaker A:** Okay, great, perfect. So, can you tell me the reason what brought you into the hospital? **[1:53] Speaker B:** I had a low blood sugar. **[1:54] Speaker A:** Okay, perfect. So, when you're telling me that you had a low blood sugar, can you tell me what makes that better and or worse? **[2:02] Speaker B:** Um when I when I get don't eat enough. **[2:04] Speaker A:** Okay. All right, what about how often that happens? **[2:07] Speaker B:** Um not not too often. **[2:08] Speaker A:** Okay. What about do you have any issues in regards to like any any weakness or dizziness or nausea with that? Does that ever happen to you? **[2:17] Speaker B:** Yeah, dizziness and and and weakness and then some sweating. **[2:20] Speaker A:** Okay. How bad does it get? Sometimes people can get to where they get really lethargic or tired, they pass out, anything like that ever happen to you? **[2:29] Speaker B:** Not like that. Just just dizzy and weak and I guess so. **[2:32] Speaker A:** Okay. Any particular time of when this happens? **[2:36] Speaker B:** Um mostly just when I when I don't eat enough. **[2:38] Speaker A:** Okay. Okay, that makes it okay. What about do you have any past medical history that may actually contribute to any of that? **[2:45] Speaker B:** I type 1 diabetic. **[2:47] Speaker A:** Okay. All right, that makes sense. Okay, so Brandon, my next question to you is what would you like to happen while you're here in the hospital with us? **[2:54] Speaker B:** I'd like to not have to come back. **[2:56] Speaker A:** Yeah, that's fair. I don't blame you. All right, perfect. So, the next thing I would like to do is go ahead and assess your airway and your breathing. So, when I'm looking at you, I see already that Brandon doesn't have any labor breathing. He has symmetrical chest rise and fall. He doesn't have an artificial airway and he's breathing on his own. The next thing I'd like to ask you, Brandon, are you having any distress, any trouble breathing, or has that ever happened to you? **[3:20] Speaker B:** No. **[3:20] Speaker A:** Okay. All right, perfect. So, now I want to go ahead and assess your heart and your lung sounds. I'm going to go ahead and lower this bed rail just get to where I'm not bending over that. So, I'm going to listen to your heart and your lungs, but I'll be listening to your front and your back as well. And you can just breathe normally for me. So, for this demonstration, I'm going to go ahead and listen on top of his gown, but really best practice, if it's appropriate and your client allows that, really stethoscope to skin, you can hear much better. All right. So, I'm going to go ahead and listen to you just breathe normally. **[4:06] Speaker A:** Okay, perfect. **[4:37] Speaker A:** Good. Can you go ahead and sit up for me, Brandon? Perfect. **[5:04] Speaker A:** Good. Last one. All right, perfect. You can go ahead and lean on back. All right, Brandon, your um heart sounds really good. Um it sounds regular rate rhythm. I didn't see any extra beats or hear any extra beats or anything like that. So, sounded nice regular strong. Right. All right, perfect. The other thing I want to tell you, your lungs sounded great. So, I always like to listen to your front and your back side and those all sounded clear, so that was good as well. All right. **[5:31] Speaker A:** Now, Brandon, I'd like to go ahead and move on to your abdomen. So, in most cases when we are um starting abdominal assessment, we want to inspect the skin. Now, for this demonstration for privacy, I'm going to go ahead and leave the gown down, but you want to make sure on inspection you look for any masses, any uh major bruising, any wounds, or anything of that nature. So now, Brandon, do you have any wounds or anything with your stomach? Any abnormal bruising, any masses I need to be aware of? **[5:57] Speaker B:** No. **[5:57] Speaker A:** Okay. All right. So next, I want to go ahead and auscultate, meaning I'm going to listen to your bowel sounds. I'm going to start here in your right lower quadrant. You could just relax for me. Perfect. Good. Just making sure I did detect bowel sounds in all quadrants. All right, very good. Okay, so I hear normal active bowel sounds in all quadrants. Now, I'm going to go ahead and what we call is palpate or kind of feel around on your stomach. Now, anytime if I push a little bit, if it's uncomfortable or it hurts, please let me know. Okay? All right, let me go ahead and start on this side. Good. Now, if the patient was like grimacing or guarding, or you feel any rebound tenderness, that's something we want to report. Does that all feel okay to you? Okay, perfect. All right. Now next, Brandon, I would like to ask you um have you had a bowel movement recently? **[6:58] Speaker B:** Yeah. **[6:58] Speaker A:** Okay, perfect. Was that normal for you? **[7:00] Speaker B:** Yes, it was. **[7:01] Speaker A:** Okay, and you said it was recently. Can you tell me was it yesterday, today? **[7:05] Speaker B:** It was yesterday. **[7:05] Speaker A:** Yesterday. Okay, perfect. What about appetite? Have you been eating well? Has that been normal for you? **[7:10] Speaker B:** Yes. **[7:10] Speaker A:** Okay, and what about urination? Like any oh, issues um starting your stream or pain with urination? Has your urine color looked normal for you? **[7:20] Speaker B:** Yes. **[7:20] Speaker A:** Okay. All right. All right, perfect. Great. **[7:23] Speaker A:** So now that we've assessed our abdomen, we're going to go ahead and move on to the extremities. So Brandon, I'd like you to just put your arms out and kind of relax. I'm going to assess your circulation. So I'm going to take the back of my hands and just kind of feel your skin temperature at this point. So I'm just feeling Sorry, my hands are probably cold. All All your skin temperature looks warm and dry. I don't see any signs of perfusion issues. I'm also going to check your radio pulses. You can just relax. Palpate both of those. All right, perfect. Those feel nice and bounding and strong. All right, next I'm going to go ahead and with your circulation, you go ahead and relax your hands. I'm going to check on your capillary refill. Make sure we're getting good circulation of flow to those. **[8:06] Speaker A:** All right, very good. And I'm also going to kind of just push on you and make sure I don't see any edema or any swelling. All right, great. So, now I'd like to go ahead and assess your strength. This is part of your neurological status. So, if you would put your arms out for me. I'm going to have you I'm going to push down on your arms. I want you to resist me. So, go ahead and resist. Very nice. Good. So, now I want you to take my hands and give it a hard squeeze. Don't be shy. Perfect. Now, pull me. Very good. Now, resist me when I pull you. Very good. All right, perfect. So, now I want you to go ahead and if you will close your eyes, what I'm going to do is test your sensation. So, tell me if you feel both sides. **[8:44] Speaker A:** Or if they feel any different. Okay, you can go ahead and open them. That feel about the same each side? Yeah. Okay. What about numbness, tingling anywhere? Any issues with that? Okay, perfect. So, now I'm going to go ahead and move down your extremities and we're going to do the same thing. All right. Okay, so I may go ahead with my hands. All right, good. Your skin feels nice, warm and dry. So, that's perfect. All right, I'm going to go ahead and feel your dorsalis pedis up top here. Checking your circulation. Good. We're also going to test your posterior tibs, posterior tibials. **[9:25] Speaker A:** Okay, great. Those feel good, too. And I also would check your circulation or your capillary refill and of all of your extremities. All right, perfect. So, now we're going to go ahead and move on to strength. So, what I want you to do is push on me like you're pushing on the gas. Perfect. Now, pull towards your face. Very good. Okay, so the next thing I want you to do, too, um if you were going to raise this foot to my hand, I'm going to count to five. Go ahead and raise that up. Try to keep it up there. 1 2 3 4 5. Very nice. Now, we're going to do the same on this one. Ready? 1 2 3 4 5. Very good. So, sometimes when we do that with patients, you'll notice that they can't either even raise their lower extremities off the bed, or you'll start seeing them come to your hand and then it starts drifting. **[10:16] Speaker A:** So, that's something you want to assess. Now, I want to go ahead and test your sensation. So, if you would have go ahead and close your eyes. I'm going to do the same thing. All right, perfect. Does that feel about the same? Yep. Okay, also one last thing I need to check as well is make sure you don't have any edema. So, I'm just going to push on you. Make sure I don't see any extra fluid there, and I don't. Perfect. Okay. I'm going to go ahead and cover you up. Thank you, Brandon. **[10:42] Speaker A:** All right. So, now that we've done that, uh when I've done my assessment, I've been checking his skin integrity throughout. The other thing I see that he's in a comfortable position, and if there's any specific lines, I want to check that, meaning tubes, lines, or drains. So, if Brandon had an IV, for example, Brandon, if you had an IV in your arm, I want to make sure that there's no redness, there's no swelling, if we injected something into it, gave you a medicine through your IV, it doesn't hurt. That's also very important if you ever have one. The other thing, if Brandon had IV fluids going, we want to make sure he's got the correct fluids. That's very important, and that happens also at the correct rate. And if you had oxygen on, we want to make sure it's on the right setting, and be careful about any lines or drains or anything on the insertion site to check the skin integrity. **[11:31] Speaker A:** And of course, if the patient has any uh surgical dressings or any dressings, to make sure those look correct and secure. So, that wraps up our assessment for today. So, thank you so much for uh participating with me. All right, so before I leave them, make sure I put your bedside rail back up. I'm going to make sure the bed is in the lowest position. And thank you for watching.