How to Conduct a Head-to-Toe Assessment
Step 1: Establish Trust
When beginning an assessment, Zucchero says, “Establishing a personal relationship of trust and respect between the patient and the nurse is vital.” She adds that it is important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable. You'll want to introduce yourself to the patient and explain the assessment process
Step 2: Confirm the patient’s ID
Step 3: Note The patient's Appearance and Status
“During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”
Step 4: Assess the ABCs
Prior to starting a detailed assessment, you'll want to assess the ABCs - airway, breathing, and circulation.
Usually, the assessment begins with the least invasive to most invasive, allowing time for the patient to become more comfortable with the examiner. It also increases the likelihood that the examiner will not forget a system during the exam.
Step 5: Look for Abnormalities
Differentiating normal from abnormal is an important skill, Zucchero explains.
Some examples of major abnormal findings are changes in normal respiratory rate that indicates respiratory distress, or a change in skin color such as pallor that may indicate anemia or jaundice that typically indicates liver problems.
Generally, the human body is bilaterally symmetrical. When you are examining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has a limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue
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