Everything You’ll EVER Need to Know About Head-to-Toe Assessments!

The BEST Online Head-to-Assessment Guide for Nurses!

What is a head-to-toe assessment?

This is a complete guide that will take you through each step of a head-to-toe assessment. It is very easy simple, easy to follow, and effective. It will answer virtually any questions you could ever have about head-to-toe assessments!

This is part 3 of a 5 part series covering health assessment. Part 1 is a step-by-step guide of a health history. Part 2 is an overview of a physical assessment. Part 3 is everything you need to know about vital signs. Part 5 covers a mental assessment.

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Nursing Necessities Cheat SheetComplete Head-to-Toe Assessment (Nursing)

 

  • Preparation
    • Wash your hands on entering the room
    • Introduce yourself to the patient
    • Explain what a head-to-toe assessment is and why you are completing it
      • It is an assessment of each of the body systems to get an understanding of the patient’s current general health status

 

  • General Survey
    • As you introduce yourself to the patient and obtain a health history note the following:
      • Asleep, awake, easily aroused?
      • Eye contact (signs of abuse or cultural differences)
      • Appearance (dressed appropriately for weather?)
      • Hygiene
      • Respiratory effort
      • Skin color (flushed, pale, etc.)
      • Speech (education level; impairments?)
      • Pain
      • Signs of distress
      • Alert and oriented (A&O) – to person, place, and time
    • Start with this to get a broad idea of their mental status
  • Vital Signs
    • Body temperature
      • 6°F
    • Pulse (chart)
      • Rate (60-100bpm)
      • Rhythm (steady)
      • Intensity
      • Compare pulses bilaterally and compare
PULSES: Peripheral pulses should be compared for rate, rhythm, and quality.
0 Absent
+1 Weak and thready
+2 Normal
+3 Full
+4 Bounding

 

 

 

 

 

  • Respirations
    • Number of breaths taken per minute (12-20)
      • Count number of breaths taken in 30 seconds and multiply by 2
      • One inhalation and one exhalation = one breath
      • Do not tell patient you are measuring their breathing rate – it affects the results
    • Blood pressure
      • 90-120mmHg/60-80mmHg
    • Oxygen Saturation
      • 95%-100%

 

  • Nutrition Status
    • Height (cm)
    • Weight (kg)
    • Lifestyle (active/moderate/sedentary)
    • Diet
    • Risk factors for altered nutrition status

 

  • Neurological
    • Stimulus response
    • Chart level of arousal by:
      • Stimuli needed to elicit response (auditory, physical, painful)
      • Type of response elicited (no response, wincing, eye-opening, etc.)
    • Glasgow Coma Scale
      • Best response: 15
      • Comatose client: 8 or below
        • Indicates severe head injury
      • Totally unresponsive: 3
  • Pupils – PERRLA
    • P – Pupils
    • E – Equal (size)
    • R – Round (shape)
    • R – Reactive to
    • L – Light and
    • A – Accommodation
  • Deep tendon reflexes
    • 0+ = reflex absent
    • 1+ = sluggish/diminished
    • 2+ = normal
    • 3+ = slightly hyperactive
    • 4+ = hyperactive with clonus
  • Motor function
    • Squeeze with both hands at same time
    • Push with both feet at same time
    • Note any one-sided weakness or drooping
  • Sensory function
    • Touch
    • Pain
    • Temperature
    • Pressure
    • Vibration
    • Vision
    • Hearing
    • Smell
    • Taste
  • Mental status exam
    • Appearance
    • Behavior
    • Insight
    • Intellectual functioning
    • Judgement
    • Memory
    • Mood and affect
    • Orientation
    • Perceptual processes
    • Sensorium
    • Thought content
    • Thought processes
  • Short Portable Mental Status Questionnaire (SPMSQ)
    • Series of 10 common knowledge question related to orientation
    • 0-2 errors = intact intellectual functioning
    • 3-4 errors = mild intellectual impairment
    • 5-7 errors = moderate intellectual impairment
    • 8-10 errors = severe intellectual impairment

 

  • Respiratory
    • Anteroposterior : transverse diameter = 1:2
      • 1:1 = barrel chest (COPD)

1:2           1:1 (barrel chest)

  • Breathing difficulty
  • Both sides rise evenly
  • Sputum
    • Color
    • Consistency
  • Cough
    • Productive
    • Nonproductive
  • Is patient receiving supplemental oxygen?
  • Breathing patterns
    • Abdominal respirations – breathing accomplished by abdominal muscles and diaphragm
    • Apnea – temporary cessation of breathing
    • Cheyne-Stokes – breathing becomes deeper and faster, then decreases to apnea, then repeats
    • Dyspnea – difficult or painful breathing
    • Hyperpnea – extremely deep breathing
    • Hyperventilation – extremely rapid, deep breathing
    • Hypoventilation – extremely slow breathing
    • Kussmaul’s – marked increase in depth and rate (appears hungry for air)
    • Orthopnea – body must be upright to breathe
    • Paradoxical – one lung deflates during inspiration
    • Periodic – pauses in breathing for 10 seconds followed by rapid shallow breaths
  • Breathing Sounds
    • Crackles – brief rattling sound caused by explosive opening of small airways, usually due to inflammation.
    • Rales – small clicking, bubbling, or rattling sounds in lungs heard on inhalation. May be described as moist, dry, fine, or coarse
    • Rhonchi – low-pitched, snoring, gurgling sound
    • Stridor – extremely high-pitched “wheeze” usually due to blockage of air flow in trachea
    • Wheeze – high-pitched sound produced by a narrowed or obstructed airway best heard on exhalation (asthma)

Order of auscultation

  • Cardiac
    • 5 P’s of circulation
      1. Pain – is it present?
      2. Pallor – is extremity losing color?
      3. Paralysis – is extremity losing mobility?
      4. Paresthesia – is there a tingling sensation?
      5. Pulse – is it palpable?

Common areas to palpate a pulse

  • Capillary refill (<3 seconds)
  • Jugular veins
  • Telemetry (heart rhythm)
EDEMA: Assess by placing thumb over dorsum of the foot or tibia for 5 seconds
0 No edema
1+ Barely discernible depression
2+ A deeper depression (< 5 mm) w/ normal foot & leg contours
3+ Deep depression (5-10 mm) w/ foot & leg swelling
4+ Deeper depression (> 1 cm) w/ severe foot and leg swelling
  • Edema (especially in legs) (chart)
  • Normal heart sounds
    • S1 (“lub”)
      • Closure of tricuspid and mitral valves. Dull and low-pitched.
    • S2 (“dub”)
      • Closure of aortic and pulmonic valves
    • Abnormal heart sounds
      • S1 split
        • S1 sounds like it is split in half
      • S2 split
        • S2 sounds like it is split in half
      • S3 (ventricular gallop)
        • Normal in healthy children
        • Abnormal in adults
        • Sounds like “Kentucky
          • S1         S2      S3
          • “Ken”     “tuck”   “ee”
          • “Lub”     “dub”     “dub”
        • S4 (atrial gallop)
          • Sounds like “Tennessee
            • S1         S2       S3
            • “Ten”     “ne”     “see”
            • “Dub”     “lub”     “dub”
          • Pericardial friction rub
            • Coarse, grating sound over heart
            • Have patient hold his breath. If sound continues, it is of cardiac origin (not pleural)
          • Mediastinal crunch
            • Sounds like popcorn crunching
            • Indicates air in mediastinum
          • Heat Murmurs (include chart)
            • Caused by increased flow through normal structures
            • Systolic murmur – occur between S1 and S2
            • Diastolic murmur – occur between S2 and S1
  • Grades of murmurs:
  • Order to auscultate
    • Mnemonic to remember each one: All People Enjoy The Mall – 2, 2, 3, 4, 5 (intercostal spaces)
    • A – Aortic – 2nd right intercostal space
    • P – Pulmonic – 2nd left intercostal space
    • E – Erb’s Point – 3rd left intercostal space
    • T – Tricuspid – 4th left intercostal space
Grade I Faint; heard with concentration
Grade II Faint murmur heard immediately
Grade III Moderately loud, not associated with thrill
Grade IV Loud and may be associated with a thrill
Grade V Very loud; associated with a thrill
Grade VI Very loud; heard w/stethoscope off chest, associate w/a thrill
  • M – Mitral – 5th left intercostal space

 

  • Integumentary
    • Color
      • Pink (normal)
        • In patients with dark skin, it is easier to assess the mucous membrane or conjunctiva
      • Pale
      • Flushed
      • Red
      • Brown
      • Yellow (jaundice)
      • Mottled
    • Texture
      • Dry
      • Moist
      • Diaphoretic
    • Injuries (find out cause)
      • Scars
      • Bruises
      • Lesions
      • Rash
    • Temperature
      • Warm
      • Hot
      • Cool
    • Turgor
      • Pinch skin – tented less than 3 seconds is normal
    • Decubitus ulcers (bony prominences)
      • Stage 1 = redness
      • Stage 2 = break in skin
      • Stage 3 = visible muscle
      • Stage 4 = visible bone
      • Unstageable = full thickness tissue loss
  • Hair
    • Even distribution?
    • Alopecia – hair loss/thinning
    • Hirsutism – abnormal excess

 

  • Head
    • Size
    • Shape
    • Symmetry
    • Cranial nerve function

 

  • Eyes
    • Symmetrical
    • Color of sclera and conjunctiva
    • Peripheral vision
    • Acuity
      • Snellen chart (20/20 is normal)

 

  • Ears
    • Pull pinna up and back to examine patient’s 3 years of age and greater
    • Pull pinna down and back to examine patient’s under 3 years of age

 

  • Nose/Sinuses
    • Alignment (septum)
    • Discharge
      • Color
      • Consistency

 

  • Mouth
    • Mucosa
    • Teeth
      • Chips, cavities, missing, dentures
    • Tongue
      • Color, hygiene
    • Tonsils
    • Ability to swallow

 

  • Nails
    • Color
    • Shape
      • Normal = angle of nail bed is less than 160 degrees
      • Clubbing = angle of nail bed is greater than 180 degrees
        • Due to prolonged decreased oxygenation
  • Breasts
    • Size
    • Shape
    • Symmetry
    • Masses or lumps
    • Gynecomastia – enlarged breasts in males
  • Abdomen
    • Order of abdominal assessment is different than other areas of body
      • Inspect
      • Auscultate
      • Percuss
      • Palpate
    • Symmetry
    • Contour
      • Flat
      • Rounded
      • Protuberant
      • Scaphoid
    • Palpate for rebound tenderness
  • Gastrointestinal
    • Inspect
      • Flat
      • Rotund
      • Distended
    • Auscultate
      • All 4 quadrants
        • Right upper quadrant
        • Left upper quadrant
        • Right lower quadrant
        • Left lower quadrant
      • Bowel sounds
        • Hypoactive = ❤ sounds per minute
        • Normoactive
        • Hyperactive = loud and frequent
        • Absent = no bowel sounds for at least 5 minutes of ausculating
      • Palpate
        • Pain
        • Rebound tenderness
        • Masses
      • Percuss
        • Air filled or fluid filled?
      • Nausea/vomiting?
      • Tubes present
        • Tube feedings
      • Stoma present
        • Stoma status
          • Pink (normal)
          • Red
          • Dusky
          • Dark
          • Retracted
          • Infected
        • Stool
          • Time of last bowel movement
          • Color
          • Character
          • Consistency
  • Musculoskeletal
    • Alignment of neck and spine
    • Range of motion of neck and spine
    • Joint movement
    • Muscle strength
    • Wheelchair/walker/cane?

 

  • Genitourinary
    • Urination
      • Amount (<30mL/hr is normal)
      • Color
        • Yellow
        • Amber
        • Orange
        • Pink
        • Red tinged
        • Bloody
      • Characteristics
        • Cloudy
Symptom Analysis: This assists the client in describing the problem.
P Provocate/Palliative: What caused it? What makes it better/worse?
Q Quality/Quantity: How does it feel, sound, look, how much?
R Region/Radiation: Where is it and does it spread?
S Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?
T Timing: When did it start? Sudden/gradual? How often? How long does it last?
  • Sediment
  • Abnormal odor
  • Burning
  • Frequency
  • Urgency
  • Bladder distention
  • Flank pain
  • Continent/incontinent
  • Stents?
  • Catheter?

 

  • IV Assessment
    • Type of line
      • Peripheral
      • PICC
      • Central
    • Insertion site
      • Location
      • Redness
      • Pain
      • Warmth
      • Swelling
      • Drainage
      • Gauge
    • Fluids
      • Rate
      • Lock
        • Saline
        • Heparin
      • Pain
        • Scale of 0-10
        • Wong-Baker (faces) scale for children

Top 10 Things NOT To Do In Nursing School

What NOT To Do in Nursing School

1. Lying

“Honesty is the best policy.” You’ve heard this cliche a million times, but it should never lose its meaning to you. Nursing has been ranked as the most trustworthy and ethical profession for 13 years in a row. Nursing is based on trust!

Nurses Most Trustworthy Profession
via http://www.gallup.com

Lying puts you and your patients at risk.You must tell the truth to ensure the highest quality of care. Yes, you will feel bad if you make a mistake such as a medication error. However, you will feel much worse if you don’t admit your mistake and then the patient suffers because of it. If you own up to it then you have a chance of fixing it. If you hide it then you have a chance of seriously harming your patient, and your future as a nurse as well.

Also, never lie for anyone else! If anyone (classmate, nurse, etc.) makes a mistake and is trying to cover it up, talk to your instructor about it. Saving a patient is being a hero, not a “snitch.”

2. Assuming

You know what they say about assuming! Any wise nurse will tell you that the scariest students are the ones who think they know everything. ASKING QUESTIONS IS GOOD. This is one thing I had a huge problem with in school. I was afraid of looking ignorant. Remember this: every nurse you are working with was once at the same point in their education as you. There was a point in their life where they didn’t know what the term “IV” meant. Don’t ever assume you know everything. If you are unsure at all, ask a nurse. Trust me, most of them absolutely love teaching.

Also, do not assume that you won’t get sick. VRE, C diff, and MRSA don’t care that you are a young, healthy adult. You are around contagious diseases all day and you are at risk! Stay safe by washing your hands constantly and using protective equipment such as gloves.

Bonus: By asking questions you appear genuinely interested. If you look interested, nurses are much more likely to take you under their wing and let you see/do some really neat stuff!

3. Forgetting About the Patient

Everything is for the patient.” Every change of shift as I receive report I write this at the top of the page. It is really easy to get caught up in the madness of charting, communicating, and delegating and forget the reason behind everything you are doing. Everything is for the patient.

If you ever think you are “above” doing a task that benefits the patient then nursing is not for you. You will walk patients to the bathroom. You will pass food trays. You will wipe more butts than you ever thought possible. Just because a task doesn’t require specific nursing knowledge or critical thinking, it does not mean you are above it. Everything is for the patient.

Patient Tux icon
Remember that every decision you make affects your patients.

Read this to learn how to assess your patients quickly and accurately every time!

4. Arguing With Professors

There are two ways to discuss answers with professors. One, argue with them. Two, discuss with them.

Where will arguing get you? You will be on the professor’s bad side. Other professors/administration will likely hear about it and you will be on their bad side. You won’t learn anything. I almost guarantee they won’t overturn a confusing question/answer, and since the questions make you choose the MOST correct answer there is often a lot of confusion.

Where will discussing the answers get you? You can have an intelligent conversation that makes the professor see both sides of the question. They can explain why one answer is definitively better than the other, so you won’t make the mistake again. They may even decide to nullify it if the question is just poorly written.

5. Getting Involved with Anything Unprofessional

Leave your past in the past. If you use illicit drugs you need to stop. Don’t bully or use profanity on social media. Be responsible when drinking. Most schools have a zero tolerance policy. Even if your school doesn’t catch you, your background check for state boards will.

I read of a student that got a DUI while in nursing school. They only had a couple drinks and just barely peaked above the legal limit. After disciplinary meetings with the administration of their school, they were luckily allowed to remain in the program. Even though they had great grades and an awesome resume, they ultimately dropped out because they were afraid they wouldn’t pass the background check. It only takes one time, and it CAN happen to you! Don’t let your dreams crumble due to one silly mistake.

6. Wearing Your Scrubs Everywhere

Showing that you’re proud of being a nurse is fantastic! However, you should not wear your scrubs everywhere you go.

First, they may be contaminated. If you wear your scrubs to work and then go somewhere crowded before changing, you are putting everyone around you at risk.

Second, they represent your school and the profession of nursing. Both reputations will be damaged if you are caught in public drinking, smoking, gambling, etc. in your scrubs. You could also get in trouble with your school.

The one place you should be wearing your scrubs is clinical. Check out the Top 10 Expert Tips to Dominate Your Nursing Clinicals!

7. Overbooking Yourself

Nursing students are notorious for working hard and staying busy. We love being involved in a ton of organizations, groups, and extracurricular activities. When entering nursing school, you need to start out small. I suggest waiting at least a semester before joining anything. As you become acclimated to nursing school and realize how much free time you have for other activities, you can begin to add more in.

Nursing school must be priority number one. Find one or two groups or activities that you truly love and stick with them.

Read The Top 10 Tips to Overcome Stress in Nursing School for more tips on how to use your time efficiently!

8. Procrastinating/Cram Studying

If you fail to prepare, you are preparing to fail. This should be your motto every single day in nursing school. You probably coasted through high school due to your intelligence and good memory. Unfortunately, that just isn’t possible in nursing school. Even if you’re ridiculously smart, nursing requires critical thinking that can only be honed by studying.

Preparing leads to:
– Saving time
– Retaining more information
– Less stress
– Less anxiety
– Better understanding of information
– Better grades
Procrastinating leads to:
– Wasting time
– Temporary knowledge
– Extreme stress
– Test anxiety
– Poor understanding of information
– Worse grades

Read Top 10 Study Hacks to ACE Your Next Nursing Exam for simple tips to boost your grades!

amanda bynes animated GIF

9. Listening to Naysayers

Any time in your life you are doing something positive there will be people there to put you down for various reasons. Your friends might say it’s taking up too much of your time. Your advisors might say nursing school is really hard. Your instructors may say nursing isn’t for you if you can’t deal with blood/vomit/etc.

All three of these happened to me. Not only did I pass nursing school, I thrived! How you respond to negativity is up to you. I chose to prove everyone wrong, and with hard work and determination I was able to.

10. Thinking You’re Not Good Enough

Nursing school will take you to new lows. Failing a nursing exam is a lot more stressful than failing a high school math exam. There will be classes you struggle with while it seems like everyone else is excelling in them. Remember this one quote that got me through nursing school: “Just give your best, because in the end that is all you can give.” Don’t compare yourself to everyone else, just make sure you are giving it everything you have every single day.

Maybe you don’t ace every test. Remember that they don’t test you on how compassionate you are. They don’t test you on how good of an advocate you are for your patients. They don’t test you on how good you can make your patients feel.

If you need some motivation to get you through the week, check out this video of a little girl with cancer “marrying” her favorite nurse!

BONUS TIP – Giving Out Personal Information

Never ever for any reason ever give out personal information to patients. You have a professional relationship with them. Do not give them your last name, address, phone number, email address, or social media usernames. In a nutshell, don’t give them any way to contact you or know where you are outside of the hospital. This is for your safety and privacy.

I had the privilege of caring for a patient that was actually enrolled in the same college as me. He saw the patch with our school’s name on it. When he asked to add me on Facebook I told him the school of nursing wouldn’t allow us to be in contact with any patients outside of the hospital. It was a little bit awkward, but it saved us both from potential trouble. Stay safe!

What else would you warn your classmates not to do in nursing school? Leave a comment telling us!

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Have a great day!

Everything You’ll Ever Need to Know About Vital Signs!

Complete Guide to Vital Signs!

This is part 3 of a 5 part series covering health assessment. Part 1 is a step-by-step guide of a health history. Part 2 is an overview of a physical assessment. Part 4 is the step-by-step guide of a head-to-toe assessment. Part 4 covers a mental assessment.

What are Vital Signs?

Check out this FREE, complete guide to vital signs!

0001 human anatomy 2

In this complete guide you will learn the following:

  1. What are vital signs?
  2. What are baseline vital signs?
  3. Body temperature
    1. How to assess
    2. Normal limits
  4. Pulse/heart rate
    1. Technique
    2. Normal limits
    3. Sites to palpate
    4. Sites to auscultate
    5. Intensity of pulse
  5. Respiration
    1. Breathing patterns
    2. Breathing sounds
    3. Technique
  6. Blood pressure
    1. Technique
    2. Systolic vs. diastolic
    3. Hypertension vs. hypotension
    4. Pulse pressure
  7. Oxygen saturation
    1. Technique
    2. Normal limits
  8. Bonus: Pain
    1. How to measure it
    2. Behaviors indicating pain
    3. 2 mnemonics to aid in remembering how to assess pain

Free Cheat Sheets For Everyone!

We also want to remind you to subscribe to the Ace Nursing School Blog Newsletter, where you’ll receive free cheat sheets every single week! No personal information required, no spam, just cheat sheets!

Nursing Necessities Cheat SheetAce Nursing School – Complete Guide to Vital Signs!

  • Vital signs
    • Clinical measurements that specify the state of a patient’s essential body functions.
    • Baseline vitals – used to determine a patient’s typical state of health.
      • Variation from baseline typically signify a change in physiological function
    • List of vital signs*:
      1. Body temperature
      2. Heart rate (pulse)
      3. Respiratory rate (and breathing sounds)
      4. Blood pressure
*For a free cheat sheet that includes vital sign normal values for each age group sign up for the Ace Nursing School Newsletter!

Oxygen saturation

  • Body temperature
    • Measurement between heat lost and heat produced by body
    • Measured by a thermometer
      • Orally (under tongue)
        • 6°F, 37.0°C
      • Axillary (under arm)
        • 6°F, 36.5°C
      • Rectal (in rectum)
        • 6°F, 37.6°C
      • Temporal (forehead/temple)
        • 6°F, 37.0°C
      • Maintained by homeostasis
        • Heat is lost through perspiration, respiration, and excretion
        • Heat is gained through digestion and muscle contraction
      • Hyperthermia – elevated body temperature in relation to body’s inability to effectively reduce heat
        • Fever – when the body is above 101°F.
      • Hypothermia – decreased body temperature due to prolonged exposure to cold temperature
        • Classified as any body temperature below 96°F
      • Factors affecting body temperature
        • Dehydration
        • Environment
        • Recently eating/drinking something hot/cold
        • Infection
  • Heart Rate / Pulse
    • The number of times the heart beats in one minute
    • Techniques:
      • May be assessed by palpation or auscultation
      • Use tips of index and middle finger to palpate
      • Count number of pulsations per 30 seconds and multiply by 2
    • Assess:
      • Rate (60-100bpm)
      • Rhythm (steady beat)
      • Intensity (explained below)
    • Common sites to palpate
    • Pedal Intensity
      • 0+ = no palpable pulse
      • 1+ = weak, “thready” pulse
      • 2+ = slightly diminished pulse
      • 3+ = normal palpable pulse
      • 4+ = bounding pulse
    • Common sites to auscultate
      • Mnemonic to remember each one: All People Enjoy The Mall – 2, 2, 3, 4, 5 (intercostal spaces)
      • A – Aortic – 2nd right intercostal space
      • P – Pulmonic – 2nd left intercostal space
      • E – Erb’s Point – 3rd left intercostal space
      • T – Tricuspid – 4th left intercostal space
      • M – Mitral – 5th left intercostal space
    • Factors affecting pulse
      • Drugs, exercise, age, gender, temperature, blood pressure, pathology
  • Respiratory rate / Breathing Sounds
    • The number of breaths taken per minute
    • The process of inhaling oxygen and exhaling carbon dioxide from the lungs
    • One complete breath consists of inhalation and exhalation
    • Assess by observing or feeling the chest for 30 seconds, counting the number of breaths, and multiplying by 2
    • Assess:
      • Rate (12-20 breaths per minute)
      • Pattern (even bilaterally0
      • Depth (normal)
      • Difficulty (unlabored)
      • Breath sounds (clear)
    • Pattern to auscultate
    • Breathing Patterns
      • Abdominal respirations – breathing accomplished by abdominal muscles and diaphragm
      • Apnea – temporary cessation of breathing
      • Cheyne-Stokes – breathing becomes deeper and faster, then decreases to apnea, then repeats
      • Dyspnea – difficult or painful breathing
      • Hyperpnea – extremely deep breathing
      • Hyperventilation – extremely rapid, deep breathing
      • Hypoventilation – extremely slow breathing
      • Kussmaul’s – marked increase in depth and rate (appears hungry for air)
      • Orthopnea – body must be upright to breathe
      • Paradoxical – one lung deflates during inspiration
      • Periodic – pauses in breathing for 10 seconds followed by rapid shallow breaths
    • Breathing Sounds
      • Crackles – brief rattling sound caused by explosive opening of small airways, usually due to inflammation.
      • Rales – small clicking, bubbling, or rattling sounds in lungs heard on inhalation. May be described as moist, dry, fine, or coarse
      • Rhonchi – low-pitched, snoring sound
      • Stridor – extremely high-pitched “wheeze” usually due to blockage of air flow in trachea
      • Wheeze – high-pitched sound produced by a narrowed or obstructed airway best heard on exhalation (asthma)
      • Factors affecting respiration
        • Anxiety, fever, drugs, pathology
  • Blood Pressure
    • The pressure of blood pushing against vessel walls as it travels through the circulatory system
    • Measured with a sphygmomanometer
    • How to measure blood pressure
  1. Place patient’s arm at heart level and rest it on a stable surface
  2. Snuggly wrap the cuff around the upper arm
  3. Find the patient’s brachial pulse and place the diaphragm of your stethoscope over it
  4. Close the air valve and use the rubber bulb to inflate the cuff to approximately 180mmHg
  5. Open the valve slowly, at approximately 3 mmHg per second
  6. Listen closely for a thumping sound, also known as Korotkoff sounds
  7. When you start hearing thumping, remember the number on the dial – this is your systolic number
  8. When you stop hearing the thumping, remember this number on the dial – this is your diastolic number
  • Systolic blood pressure
    • Top number in the fraction
    • Highest level blood pressure reaches when the heart contracts
    • Normal limits are 90-120mmHg
  • Diastolic blood pressure
    • Bottom number in the fraction
    • Lowest level blood pressure reaches as the heart relaxes
    • Normal limits are 60-80mmHg
  • Pulse pressure
    • Difference between systolic and diastolic values (30-40mmHg)
  • Hypertension (high blood pressure)
    • Occurs when blood pressure is greater than 140/90mmHg
  • Hypotension (low blood pressure)
    • Occurs when blood pressure is lower than 100/60mmHg
  • The cuff must be cover at least 2/3 of the patient’s upper arm
  • Factors affecting blood pressure
    • Anxiety, drugs, cardiac output, vascular resistance, arterial elasticity, blood volume, weight, exercise, pathology
  • Oxygen Saturation (SpO2)
    • Measures the percentage of hemoglobin that is loaded with oxygen
    • Normal limits are 95%-100%.
    • Measured through use of a pulse oximeter (noninvasive)
      • Commonly placed on a fingertip or ear lobe
    • Factors affecting oxygen saturation
      • Nail polish, cold extremities, pathology
  • Bonus: Pain
    • Considered by some facilities and organizations as a vital sign
    • Measured on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable.
      • The patient is the only person who can truly state a pain level – as a nurse we must record the patient states
    • Measured by pictures in those who cannot speak or understand the numerical scale
    • Behaviors indicating pain
      • Clenched teeth
      • Wrinkled forehead
      • Biting lips
      • Tightly closed eyes
      • Crying
      • Moaning
      • Restlessness
      • Muscle tension
      • Silence
      • Withdrawal
    • OLDCART
      • O – Onset
      • L – Location
      • D – Duration
      • C – Characteristics
      • A – Aggravating factors
      • R – Radiation
      • T – Treatment (what makes it better?)
    • PQRST
      • P – Provoke (what causes it?)
      • Q – Quality (stabbing, dull, etc.)
      • R – Region
      • S – Severity (0-10 scale)
      • T – Timing (when it started)

Physical Assessment Teqhniques for Nurses

Ace Nursing School – The Best Resource for Nursing Students!

This is part 2 of a 4 part series covering health assessment. Part 1 is the overview of a health history. Part 3 is a complete guide to vital signs. Part 4 is a step-by-step guide of a head-to-toe assessment. Part 5 covers a mental assessment.

What Is Needed to Perform a Physical Assessment?

Check out this FREE, concise overview of what a physical (head-to-toe) assessment is!

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In this overview you will learn the following:

  1. The purpose of an assessment
  2. The guidelines/preparation for an assessment
  3. The 4 techniques of a physical assessment
    1. Inspection
    2. Palpation
    3. Percussion
    4. Auscultation
  4. The order the 4 techniques should be performed in
  5. What a focused assessment is
  6. The nursing process, and how the assessment plays a role in it

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Nursing Necessities Cheat Sheet

Ace Nursing School – Physical Assessment Overview for Nurses

  • Purpose
    • Assessment is the first step of the nursing process
    • Nursing diagnoses, planning, and interventions are based on the assessment
    • Notify the physicians with any abnormal findings of concern
  • Guidelines
    • Gather equipment
    • Explain assessment to patient
      • Each time you move to a new technique, explain to the patient what you are doing beforehand
    • Position bed at comfortable height for examiner(s)
    • Expose each body part as needed
      • Keep patient covered except for when a body part must be examined to maintain privacy
    • Establish rapport and trust by having an innocent conversation with patient before the assessment
    • Compare right side of the body with the left side
    • Begin with a general head-to-toe physical assessment. As problems are found/stated by the patient, focus in on those areas
      • When problems (or potential problems) are found, use it as a moment to educate the patient

 

  • 4 Techniques of a Physical Assessment
    • Inspection
      • Visually observing the patient
      • Always done before the other 3 techniques
      • Assess (and make a note of any abnormalities):
        • Size
        • Shape
        • Color
        • Texture
        • Symmetry
        • Position
  • Palpation
    • Using the hands to feel the patient or press on the patient
    • Begin light, work deeper as needed
    • Fingertips used for fine discrimination (anything that is hard to feel or tender)
      • Also good for gripping and feeling consistency of tissues
  • The back of the hand is best to palpate for temperature of body parts
  • Palms are good for sensing vibration
  • Assess (and make note of any abnormalities):
    • Tenderness
    • Size
    • Pulse
    • Swelling
    • Temperature
    • Vibration
    • Masses/lumps
    • Crepitus
    • Texture
    • Moisture/dryness
  • Percussion
    • Light striking of body parts to produce sounds
    • Direct percussion – striking of body part with finger(s), palm, or fist
    • Indirect percussion – middle finger of non-dominant hand placed on body part. Use finger(s) of dominant hand to strike the finger.
  • Blunt – using reflex hammer for deep tendon reflexes
  • Percussion sounds:
    • Resonance: loud, low pitched sound heard over normal lung filled with air
    • Hyperresonance – louder, lower-pitched sound heard over overinflated lung (emphysema)
    • Tympany – loud, drum-like sound found over air-filled viscera (stomach or bowels)
    • Dull – soft, muffled sound found with fluid-filled tissue (liver)
    • Flat – soft, high-pitched sound found with very dense tissue such as bone or muscle
  • Assess (and make a note of any abnormalities):
    • Location, size, density of masses
    • Pain
  • Auscultation
    • Listening to the body, often done with a stethoscope
    • Bell (smaller side) is used for low-pitched sounds
    • Diaphragm (larger side) is used for higher pitched sounds
    • Listen over bare skin when possible – clothes and hair create distractive noise
  • Order of Techniques Performed
    • General Assessment (everything except abdominal assessment)
      1. Inspection
      2. Palpation
      3. Percussion
      4. Auscultation
    • Abdominal Assessment
      1. Inspection
      2. Auscultation
      3. Percussion
      4. Palpation

 

  • Focused Assessment
    • In-depth assessment that is focused on a patient’s particular need
      • Example: If the patient is having cardiovascular problems, do a focused cardiovascular assessment
    • Assess specific characteristics of problem
    • Determine what nursing intervention is necessary
    • Determine when intervention should be done
    • Detailed focused assessments will be discussed at the beginning of the chapter for each body system.
  • Nursing Process
    • Information obtained from the physical assessment is used as the base of the nursing process
    • To remember the order of the nursing process memorize: A Delicious PIE.
    • A – assessment
    • D – diagnosis
    • P – planning
    • I – Implementation
    • E – Evaluation

How Much Money Does Each Nursing Speciality Make? [Infographic]

Everything You Need to Know About Nursing Salaries!

Every future nurse has a dream of where they want to work and what they want to do. Unfortunately, it is not always fiscally possible. This infographic shows the top 10 highest paid nursing specialties and top 10 lowest paid nursing specialties.

At the bottom it even goes on to to show the average salaries for nurses in each state. The data may surprise you!

Note: These are all average, median, or starting salaries. There are always exceptions!

Top 10 Nursing Jobs of 2014

How to Make Nursing School as Simple as Elementary School!

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As always, we would love to hear your feedback! Feel free to comment below, email us at iAceNursingSchool@gmail.com, and follow us on Twitter and Pinterest. We will reply as quickly as possible!

Have a great day!

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Get Rid of Nursing School Stress Once and for All



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How Much Money Do Nurses in Your State Make?

Do Nurses Make Enough Money?

Should you stay in your home state, or are you able to travel to the area of your dreams? Which states need more nurses?

The Bureau of Labor Statistics has the answers, and they might surprise you!  Check out the statistics!

 
How to Make Nursing School as Simple as Elementary School!

Join our Ace Nursing School Newsletter and receive a FREE cheat sheets (like the one below) every single week! For more information check out Free Cheat Sheets That Nursing Students Cannot Live Without!

0001 Nursing Necessities Cheat Sheet Teaser
Sneak peek of one of our many cheat sheets.

As always, we would love to hear your feedback! Feel free to comment below, email us at iAceNursingSchool@gmail.com, and follow us on Twitter and Pinterest. We will reply as quickly as possible!

Have a great day!