Advanced physical assessment....

Advanced Physical Assessment Made Easy...The 👩‍⚕️ nursing process 🩺 is the 🔑 of all nursing practice. It's a 🗺️ to quality, holistic care that nurses consistently offer their patients. 📝 Assessment, the ☝️ step, is when the RN 👩‍⚕️ gathers data 📊 about a client’s health state. Registered Nurses 👩‍⚕️👩‍⚕️ later use this info ℹ️ to figure out a diagnosis 🤔 and choose the right nursing actions 🛠️ to help the patient get better 💪. In the assessment phase, a basic but super important tool 🧰 a nurse has is a full head-to-toe checkup. This looks at 👀 all body systems and gives valuable info 💡 about how the patient is doing overall. In this guide 📒, we’ll give you a quick look 👀 at the assessment process, and a step-by-step guide 🪜 on how to do a head-to-toe assessment. As you get more practice 🧑‍⚕️, checking patients will become normal. This checklist ✅ is the first step to help you feel confident 💪 to do these checks. Let’s start! 🚀 ❓

 What Is a Head-to-Toe Assessment? If you’re still in nursing school 🏫 or just starting your nursing journey 🌱, you might ask: What’s a head-to-toe assessment? 🤔 What does it include? ➡️ How do I do one? Simply put, a head-to-toe assessment is a thorough process ✅ that checks the health of all major body systems. It’s a full physical exam that shows 👀 a patient’s needs and problems 🤕. Doing this assessment is part of an RN’s job 👩‍⚕️, but sometimes a doctor 👨‍⚕️ or EMT 🚑 might do it too. Mostly, head-to-toe assessments happen during regular checkups 🩺 or yearly physicals. When a patient comes to the hospital 🏥 with a specific problem 🤕, the usual way is a problem-focused assessment. This means the checkup is focused on certain care goals 🎯: the health problem is known, so this exam looks at a smaller area. The head-to-toe assessment is the opposite ↔️. It’s wider and looks at all parts of the body. How long it takes depends on the patient and their general health 👍 or 👎. 🧰 What Equipment Should You Have Ready for a Head-to-Toe Assessment? 

Nurses 👩‍⚕️ who do head-to-toe assessments need to be prepared. Some basic things ⚙️ you should get ready before doing a head-to-toe check are: 🧤 Gloves 🌡️ Thermometer ⚖️ Scale 📏 Height ruler 🔦 Penlight 🩺 Stethoscope 🩸 Blood pressure cuff 👅 Tongue depressor 🩹 Sterile objects (soft and sharp) 🔎 What Methods of Examination Do You Use in a Head to Toe Assessment? There are different ways to do a physical exam. While looking at a patient closely 👀, you’ll use four main methods. Here’s a quick look: 👀 Inspection Always first!☝️ You use your eyes 👀 and nose 👃 to check body areas for normal color, shape, and feel 🖐️. 🖐️ Palpation: Touching the patient to feel for anything unusual on (or in) the body. You’ll use two kinds: light 👋 and deep 💪. Light touch tells about skin feel, wetness💧, tight muscles, and maybe some surface pain 🤕. Deep touch goes further inside (4-5 cm) to learn about organs and lumps – their place, shape, movement, and if they hurt. 👂 Percussion tapping on the patient’s body to make sounds 🎶. These sounds can show if there’s air 💨, liquid 💧, or solid stuff inside. It can also tell the size, shape, and location of organs. 🎧 Auscultation Listening to the heart 🫀, lungs 🫁, neck, or belly 🤰 to get info. Direct listening is with your ear 👂. Indirect listening uses tools like a stethoscope 🩺.

➡️ How Do You Start an Assessment? First thing ☝️ is to connect with the patient🤝. Introduce yourself 👋, explain what you’ll be doing, and ask why they’re at the doctor’s office 🏥. Answer any questions 🤔 they have before you start. Ask if you can make them more comfortable 😊, like changing the room temperature 🌡️ or lights 💡. It’s important to build trust 🤗 before the physical exam starts. From the moment you walk in 🚶‍♀️, start noticing things about the patient: 🧍 

Their general look (How’s their hygiene 🧼, clothes 👚, mood 😊?) 🧍‍♀️ Their posture (Do they have trouble sitting 🪑/standing🧍? Are they making noises when they move 🚶‍♂️?) 🗣️ Is their speech clear 👍 or mumbled 👎? 👃 Any strange smells 😷? 🧠 Are they alert 🤔? (Can they answer questions? Are they quiet 🤫?) 😥 Signs of trouble (Do they look confused ❓, pale 👻? Are they having trouble breathing 😮‍💨? Are they avoiding eye contact 👀?) Once you’ve connected with the patient 🤗, you can start the assessment.

✅ Head to Toe Assessment Checklist To make it easier for yourself, you can use a checklist ✅ or a summary of everything you need to check. This part will explain in detail what’s included in this type of assessment and give you a step-by-step guide 🪜. 1️⃣ General Overview First, get a general idea of the patient’s health 👍 or 👎. Here’s what to watch for 👀: 🩺 Take their vital signs. (Always ask permission 🙏 before touching a patient. Also, explaining what you’re doing will help them relax 😊.) ❤️ Check heart rate 🩸 Measure blood pressure 🌡️ Take body temperature 💨 Pulse oximetry 😮‍💨 Respiratory rate 🤕 Check pain levels 📏 Measure height and weight ⚖️ and calculate their BMI 2️⃣ Hair 💇‍♀️/ Skin 🖐️/ Nails 💅 Once you have a general idea, start from the top ⬆️ and go down ⬇️. It’s called “head to toe” for a reason! Some things to look for 👀: 💇‍♀️ Hair distribution (even 👍/uneven 👎) 🐛

 Hair problems (lice 🐛, bald spots 🧑‍🦲) 🤕 Bumps, nits, sores on the scalp 🤕 Soreness on the scalp 🤕 Soreness, lumps on the skin 🤕 Sores, bruises 🤕, or rashes on skin 🌡️ Temperature (cold 🥶, hot 🔥), wetness (dry 🌵, clammy 💦), and skin feel (smooth 👍, rough 👎) (Is the patient pale 👻, clammy 💦, dry 🌵, cold 🥶, hot 🔥, flushed 😊?) 🦵 Swelling 🦵 💅 How the nails look🤕 Pressure spots 3️⃣ Head 👤 ⚪ Shape is round and even 👍 🖐️ When you touch it, no bumps, lumps, or dents 👍 😊 Face looks smooth and even 👍 with no bumps or lumps 👍 4️⃣ Eyes 👀 👁️ Check outside parts ⚖️ Check if eyes are even 🔴⚪ Check the inside lining and white part 👍 🔦 Check if pupils react to light and are equal and round 👀👍 👓 Do a vision test 💧 Check for eye discharge 📊 Check vision with a Snellen chart ➡️ Check eye movement in six directions 5️⃣ Nose 👃 🖐️ Feel the nose and check if it’s even 👍 👃 Check the middle part and inside the nostrils 👍 🌬️ Check if the patient can breathe through each nostril 👍 👃 Check sense of smell 🖐️ Feel the sinuses 6️⃣ Mouth 👄 and Throat 👅 👄 Check lips for color  and wetness 💧 🦷 Look at teeth and gums 👍 👅 Look at the tongue 👍 👄 Look inside the mouth 👍 👅 Look at tonsils and uvula 👍 👅 

Ask patient to move tongue side to side to check a nerve 👍 👅 Check if the patient can taste 👅, swallow 吞嚥, and if they have a gag reflex 👍 7️⃣ Ears 👂 👂 Look for discharge or anything unusual 👍 👂 Test hearing with a whisper test 🤫 👂 Look inside the ear: check the eardrum and any discharge 👍 🎶 Tuning fork tests (Weber’s Test, Rinne Test) 8️⃣ Neck 脖子 💪 Check if neck muscles are the same size 👍 🖐️ Feel the lymph nodes 👍 ➡️ Check head movements and if they cause pain 🤕 🤸‍♀️ Watch how the neck moves 👍 🌬️ Check where the windpipe is 👍 💪 Check shoulder shrug against resistance 👍 9️⃣ Chest 🫁: Heart ❤️ Checkup Listen to the heartbeat 🩺. Listen in these areas: aortic, pulmonic, Erb’s point, tricuspid, mitral. 🖐️ Feel the carotid artery and listen to the apical pulse 🩺 1️⃣0️⃣ Chest 🫁: Breathing 😮‍💨 Checkup Listen to lung sounds front and back 🩺 🌬️ Watch how the chest moves when breathing 👍 🗣️ Ask about trouble breathing or coughing 🗣️ 🖐️ Feel the chest area 1️⃣1️⃣ Belly 🤰 👀 Look at the belly 👍 👂 Listen to bowel sounds in all four parts 🩺 🖐️ Feel all four parts of the belly for pain or tenderness 🤕 🚽 Ask about bowel or bladder problems 🚽 1️⃣2️⃣ Arms 💪 and Legs 🦵 🤸‍♀️ Check how well arms, legs, and ankles move and their strength 💪 🖐️ Check if patient can feel sharp 뾰족한 and dull 뭉툭한 things on arms and legs 👍 👀 Look at arms and legs for pain 🤕, deformities deformities, swelling 🦵, pressure spots 🤕, bruises 🤕 🖐️ Feel the radial pulses (wrist) and pedal pulses (foot) 👍 💅 Check capillary refill on fingernails and toenails➡️⚪➡️🚶‍♀️ Watch how they walk 👍 🤝 Check hand grip strength and if it’s equal on both sides 💪 1️⃣3️⃣ Back espalda 👀 Look at the back and spine 👍 🍑 Look at the tailbone area 👍 Once you’ve gone through all these steps ✅, the assessment is done 👍. Let your patient know it’s finished. Make sure they don’t have any questions 🤔 or worries 😟.

📝 Things to Keep in Mind While Doing a Head-to-Toe Assessment ✍️ Write down what you find. Doing the head-to-toe assessment is a key part of nursing 👍. So is writing down everything you find clearly and briefly 📝. What you see and write down will be the main part of the care plan later. It might help to use a head-to-toe checklist ✅ to make sure you remember and write down all the important info ℹ️. 🗣️ Talk clearly. Good communication 🗣️ is super important for good nursing care 👍. When doing a head-to-toe assessment, use this skill! Ask permission 🙏 before touching, explain what you’re doing – and why 🤔. Make it a space where patients feel okay to ask questions 🤔 or share worries 😟. ⚖️ Same on both sides. Usually, the human body is the same on both sides 👍. Anything unusual you see during your checkup needs more attention 👀. Weakness on one side? Less movement in one arm or leg? This could mean problems with nerves or muscles, so watch for differences between the right and left sides 👀.

Source-https://www.youtube.com/@hawknurse