- Develop a Framework for a Head to Toe Assessment
- Order of actions
- Exception = Abdominal Assessment
- **Palpation and Percussion may alter bowel sounds
- Maintain professionalism
- Suggested order
- General Assessment
- Can be done throughout assessment while inspecting other body systems
- Eyes, Ears, Nose, Mouth, Throat
- Heart and Great Vessels
- Thorax and Lungs
- Peripheral Vascular
- Determine if any findings deviate from normal
- If so, assess further
- Explain what you are doing as you do it
- Explain purpose for different assessments
We want to give you guys a quick introduction to Health Assessment so you have a good framework when you start to learn your head to toe assessments.
The purpose of an assessment is to gather data – what’s going on with your patient? We determine whether any of our findings deviate from what is considered to be normal. If we do find something abnormal, we will assess in more detail and see if we can determine the problem. Or, we may need to notify a provider so that they can order any necessary tests, etc. Our goal in the Health Assessment course is to give you a step-by step process for your Head to Toe assessment and to show you what to look at and look for in each body system. We’re not going to go into super deep detail about abnormal findings, because those are covered within the specific body systems and disease processes. But we are going to teach you what you’re looking for and generally what would be considered normal in each system. We also want to make sure you’re completing assessment steps in the correct order. When I say steps – the 4 basic steps for assessment are inspection, palpation, percussion, and auscultation. And in all cases except one body system, which we’ll talk about in a minute, this is the order in which the assessments should be performed. You may have some body systems where you only inspect and palpate, or some where you only inspect, palpate, and auscultate, which is fine – you just skip over the step you don’t need – but you generally always go in this order.
So what’s inspection? This is when you physically LOOK at the body and the structures involved in whatever system you’re assessing. You might be looking at color, looking for moisture or lack thereof, you might be looking for deformities or lesions or wounds, or looking at the size, shape, and symmetry of that structure. Knowing what it SHOULD look like is the most important part of assessment – if you don’t know what it SHOULD look like, then you can’t identify an abnormal finding, right? Quick tip – there is not a single body system that we DON’T inspect in some way. So ALWAYS, always, always start with inspection.
Next is palpation – this is where we feel for abnormalities. This is different depending on the body system, which we’ll cover in each specific system’s assessment lesson, but generally we might be feeling for crepitus, which is like rice crispies under the skin or a crunching feeling. We might be feeling for masses or solid organs, tenderness or pain in certain spots, or the movement of a body part – like when we assess joints and range of motion in musculoskeletal or expansion of the lungs. We feel for size and shape of things like organs or swollen glands or lymph nodes. And we also feel for pulsation or what’s called a thrill – a thrill is when you feel a swishing under your fingers, usually over some sort of vessel – we’ll talk about that more in the peripheral vascular lesson. So palpation is when we use our hands to feel for any issues.
Then, we move to percussion. To percuss, you will usually place your middle finger on the patient’s skin over the area you want to percuss – so let’s say this is the patient’s chest. Then you use the first two fingers of your other hand and you tap on your middle finger. When you do that, you’re going to hear a sound. It could sound like a drum, which would be tympanic – which usually happens over air-filled spaces like the abdomen. It could sound hollow, which would be called resonant – this happens over air filled structures like the lungs – this is normal. It could also be hyperresonant – the best way to hear what this sounds like is to puff out your cheeks and flick or tap on your cheek. Hyperresonant sounds usually happen when there’s trapped air or air under pressure. You may hear this in a patient with COPD because they tend to have overinflated lungs, or in someone with a pneumothorax because the air is trapped around the lung. Or – you could tap on your finger and basically just hear a thud. That’s called dull and that’s what you will hear over solid organs or bones or over a fluid-filled space like in a hemothorax. So here’s the best way to learn these different sounds. For tympanic – push out your belly and percuss it – it will sound like a drum beat. For resonant versus dull – find a space between your ribs on your chest and percuss, then go over your collarbone and percuss. The space will sound resonant (a little higher pitched) and the collarbone will be a dull thud. This is a difficult assessment for a lot of new nurses, but the more you practice it, the more you’ll know what you’re hearing.
Of course as we do these percussive assessments, we also want to note whether or not there’s any pain with percussion as well.
And lastly we move to auscultation. We are listening to the patient in various places. We’re listening for normal sounds, both the presence of them, what they sound like, and even how often they occur like with bowel sounds. Make sure you go to the heart sounds and lung sounds lessons, as well, to learn more about what you’re listening for here. We can also listen for what’s called a bruit – that’s a whooshing sound, usually over a blood vessel, that indicates high flow. Now, remember we can either listen with our stethoscope or with the naked ear. When you listen with your stethoscope, you can either listen with the diaphragm, which is the larger part. Or you can listen with the bell, which is the smaller part. The bell will allow you to hear softer sounds like bruits or murmurs in the heart, whereas the diaphragm allows you to hear most other sounds. You could also listen with your naked ear – when a patient bends their knee you might hear it creaking, or you might be able to hear them wheezing without even using your stethoscope. So just remember auscultation is not always just with a stethoscope.
Now – remember I told you there’s one body system that has an exception to the rule – that’s the abdominal assessment. Instead of auscultating last, we actually auscultate right after we inspect and before we palpate or percuss. Why? Well if I start smushing and tapping on your belly, there’s a great chance that I can mess with your bowel sounds and make them more or less active than they were. So it’s really important that we listen before we start messing with their belly so that we know for sure what’s going on with their bowel sounds.
Now, we are so excited to bring you specific health assessment lessons showing on a live person how to do each body system assessment and we really think they’re going to be so helpful. We just wanted to give you a quick suggested order to your head to toe assessment, because that’s the order you’ll see these lesson in IF you go into the Health Assessment course. If you’re just using the search function or the study plan within NRSNG Academy, you can type in these systems and assessment and you’ll find the lessons on each one! So you start with your general assessment – how do they look generally. You do an integumentary assessment, which, honestly you can just do throughout the other assessments as you look at various areas of the body. Then you’ll literally go head to toe – neuro, head/neck, eyes/ears/nose/ throat, heart and great vessels, thorax and lungs, abdomen, the lymphatic and peripheral vascular systems, musculoskeletal, and GU. Again, this is just a suggestion, but we always recommend you just go head to toe, literally, so you don’t miss anything!
SO remember, the goal here is to gather data and see if there are any deviation from normal. Make sure you’re assessing in the correct order – inspect, palpate, percuss, auscultate. Unless you’re assessing the abdomen, in which case you will auscultate before you palpate and percuss so that you don’t change the bowel sounds. And know that if you literally go head to toe, you can make sure you hit everything. Now – that being said, we’re going to talk in a lot of detail in each system assessment about what to look for – but if on a regular shift you go in and do this full head to toe detailed assessment, you’re going to take 30 minutes to do each assessment. That just doesn’t work. So – we’ve also added a lesson called “The 5-Minute Assessment” which shows you how to do everything you need to do quickly and efficiently in 5 minutes! So make sure you check that out.
We love you guys, we can’t wait for you to dive in and enjoy our health assessment videos. Make sure you check out all the resources attached to this lesson as well. Now, go out and be your best selves today. And, as always, happy nursing!!