by Claire Kernaghan

Created on: July 03, 2007

A head to toe nursing assessment is a simple task that any nurse can perform in a matter of minutes. It starts simply by observing the patient, checking their mobility, alertness, general hygiene, posture, ethnicity, gender, body build, weight, gait, manner of dress, mood or affect, speech content and pattern, and symmetry.

The next step would include looking at each of the body's systems and assessing them. Start with the respiratory and circulatory systems. Assess blood pressure, oxygen saturation, heart rate, respiratory rate, cardiac function, breath sounds and heart sounds. Moving on to the skin, assessing temperature, capillary refill, presence of pulses, and impaired skin integrity i.e.wounds, bruising, rashes, moles or pigmented spots and ulcers.

Moving onto musculo-skeletal system. This would involve identifying actual and potential problems with activity and movement, identifying the patients risk of developing problems with mobility, and identifying the impact of impaired musculo-skeletal function of the patients daily activities and capacity for independent self care. This would also include looking at the nervous system, examining eyes, hearing, touch, smell and taste.

Then moving onto the fluid and nutrition needs of the patient focusing on the patients diet and exercise regime and whether they are getting sufficient nutrients to meet their energy requirements including any factors that may impair their desire or cultural beliefs to be getting sufficient nutrients. This would include looking at the digestive system by checking urine and stool samples if necessary.

There are four techniques of physical examination that are used by nurses, these are:
* inspection - looking
* auscultation - listening
* palpation - relies on touch
* percussion - where the finger of one hand strikes the middle finger of the other hand which is in contact with the patients skin (by doing this we look at the pitch of the sound and that indicated swollen masses or air pockets within the body).
As always with a head to toe examination your vital signs are assessed. These include:
* temperature
* pulse
* blood pressure
* respirations, and
* oxygen saturation.

Above all remember to talk to the patient, ask them questions that may give you indications as to their overall health status such as past surgeries or injuries, if they have any allergies, what they expect from their stay in hospital and how well they can care for themselves in their own home.

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