Focused Nursing Assessment Head-to-Toe Nursing Assessment

Focused Nursing Assessment

Head-to-Toe Nursing Assessment

A head-to-toe assessment is a comprehensive nursing assessment that involves a thorough examination of a patient’s physical and psychosocial status. This type of assessment is typically performed at routine intervals on nursing units like intensive care, stepdown, and med-surg.

How Often Are Head-to-Toe Assessments Required?

If the patient is in critical care (CVICU, neuro ICU, ICU, transplant ICU etc.), hospital policy likely require a full head-to-toe assessment to be performed and documented at least every four (4) hours. If the patient is on a med-surg floor (or similar), policy likely requires a head-to-toe assessment to be performed at least once per shift, with change of care giver, or after an event/change in status (for example, after a rapid response call). A focused assessment is a type of nursing assessment that is used to gather information about a specific problem or concern related to a patient’s health status. Unlike a comprehensive assessment, which is a more thorough evaluation of the patient’s overall health status, a focused assessment is more targeted and limited to a specific area of concern. For example, a focused assessment may be performed to evaluate a patient who is experiencing chest pain. The nurse will focus on gathering information about the chest pain, such as its onset, duration, and intensity, as well as any associated symptoms such as shortness of breath, nausea, or diaphoresis (sweating). The nurse will also perform a physical examination to assess the patient’s cardiac function, including auscultating the heart and lungs, assessing vital signs, and checking for any signs of circulatory compromise. Other examples of focused assessments include:

• Skin assessment: This may be done to evaluate a patient’s skin condition, including the presence of any wounds, rashes, or lesions.
• Pain assessment: This may be done to evaluate a patient’s pain level, including its intensity, location, and duration.
• Mobility assessment: This may be done to evaluate a patient’s ability to move around, including their range of motion, muscle strength, and any signs of discomfort or pain.
• Nutrition assessment: This may be done to evaluate a patient’s nutritional status, including their dietary intake, weight, and any signs of malnutrition.

A focused assessment helps the nurse to identify specific problems or concerns, develop an appropriate care plan, and monitor the patient’s progress. It is an important tool for providing patient-centered care and ensuring that patients receive the necessary interventions to address their individual needs.

Preparing for the Nursing Assessments

Some tools that may be useful during an assessment include:

• Penlight
• Vital sign supplies: blood pressure cuff (or automated machine), thermometer, pulse oximeter
• Stethoscope
• Handheld doppler – this is necessary if you cannot palpate pulses

Your nursing school textbook will mention things like an otoscope, tongue depressor, and more. However, in routine head-to-toe assessment and focused assessments, these tools are not necessary. If you work in highly specialized areas like labor and delivery, you may need other tools.

Non-verbal Cues: Just as Important

While much of a nursing assessment focuses on biological or physiological attributes and active listening, nurses also need to be able to pick up on certain non-verbal cues. Sometimes, what a patient doesn’t say is the most critical piece of information. Non-verbal cues can include:

• If the patient is purposefully moving all four extremities spontaneously
• If the patient able to complete basic tasks without help or cueing (getting a drink of water, turning on the TV, repositioning themselves in bed)
• Able to communicate with visitor and the nurse / staff with ease
• Discomfort speaking with specific individuals or about specific topics
• Indicators of pain while completing the assessment (wincing, clenching jaw, deep breathing, tense)
• Vital sign

Pay attention as you’re entering the room, before you begin your verbal interaction, and while you perform your assessment. Also, make sure to observe non-verbal cues throughout your shift.

Building Rapport

By establishing a trusting and professional relationship with your patient, your are building rapport. This enables your patient to relax and be honest with how they are feeling and what they are thinking which ultimately enables you to obtain a more accurate assessment, and thus better provide better care. You can do this by confidently introducing yourself at the beginning of your shift. “Hi my name is Kati, and I’ll be your nurse today.” [extend hand for a handshake] This is such a small gesture, but it makes a big difference to patients and loved ones.

Communication

Communicate clearly throughout the assessment with your patient. Ask before you start touching the patient, and explain what you are doing as you do it. My favorite talking point is: “Alright, I need to look you over really quickly. Is it okay if I ask you a few questions, listen to heart and lungs, and all that jazz?” (Insert witty comment from the patient here) “Okay, can you tell me your name, what year it is, and where you are right now?” (Or some variation of orientation questions.) “Alright, I’m just going to shine this pen light into your eyes for a moment while I look at your pupils. Focus on my nose.” “Ok great, can you lean forward so I can listen to your lungs on your back? Okay great, give me some slow deep breaths.”  

Documentation

Documentation is a critical part of the assessment process. This helps you download your findings from your brain to a reliable place (the patient’s chart) so that you do not need to struggle to remember it later on, and enables nurses on future shifts to know what the patient’s assessment looked like at specific times. There have been many times as a bedside nurse in which I detect assessment changes, and immediately refer back to the chart to see what the previous nurse’s documentation showed. This is very helpful and enables you to gauge your level of urgency accordingly. Maybe you noticed what you thought was a change, but when you review documentation, it is clear that this is a known abnormality (and therefore likely does not require physician notification).

Final Thoughts on Nursing Assessments

These assessments may become routine to you, but are a one-off sometimes for patients. Having their private areas looked at, or asking personal questions can be a lot for some, so ensure that you are paying attention to their demeanor and being kind and caring. Finally, do not underestimate the power of a quality assessment. This informs physicians in their decision-making, which can be life or death. Physicians see the patient for only a few minutes each day, but the nurse is who is there 24/7. The medical team is relying on your expertise to notify them when something changes. My biggest tip for nursing assessments is to complete a solid assessment at the beginning of your shift so that later on if something changes, you have something to compare it to. Godspeed, nurses and nursing students!

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