Head-To-Toe Assessment Tips!

🩺Tiny tips to keep in your pocket for your next head-to-toe assessment

🫁When listening to posterior lung sounds, sit your patient forward and inspect the skin for redness or breakdown. This works both ways! If you’re inspecting the skin on a patient’s back or turning & positioning them, work smarter! Jump in and take the opportunity to listen to posterior lung sounds while you have the back open and clear. This is especially helpful for patients who are bedbound or have difficulty sitting forward!

⭐If you’re having trouble feeling pedal pulses, find a doppler ultrasound. These handheld machines will help you detect pedal pulses a bit more easily. NEVER assume that you’re just having a hard time feeling it. Lack of a pedal pulse can indicate problems, such as vessel occlusion or clot. Always use a doppler when you’re in doubt!

🧽Remember, unless you’re in a transmission-based precaution room, you’re probably using your stethoscope on multiple patients per day. So, be SURE to alcohol swab or sanitize with hospital-provided disinfectant wipes between each patient… infection control, infection control, infection control!

❓When you’re auscultating and assessing each body system, ask questions that make sense! (ex: abdominal assessment→ ask about last BM, any pain? Any nausea, vomiting, diarrhea? Any pain during assessment? Are they tolerating their current diet well?) These questions will help you engage with the patient and tie information together as you gather more

🫧And finally, I’ll say it again, take advantage of clustering care by working with your team and jumping in. First of all, help when you can (that’s a given), second of all, it’ll save you, your team, and the patient from needing to reposition again right afterward, especially when the patient is finally relaxed, resting, and clean. Utilizing times of bed baths, turning & positioning, and transfers to inspect the skin fully. A head-to-toe assessment truly means head to toe. So be sure to document and thoroughly assess the skin, each body system, from the head to the toes!

Have you been working on your head-to-toe assessments? What little tips have you gathered along the way?

#headtotoeassessment #nursingschool #nursingstudent #studentnurse #nurseinthemaking #nursingskills #clinicalskills #auscultation #RN #BSN