18 April 2018
How to Give a Head-to-Toe Assessment on a Patient
Hi my name is Rachel Semetsis. Today I am going to teach you how to perform a head to toe assessment on patients to monitor your overall health. To start, how many of you have visited a doctor’s office recently for a physical or check-up? For those you that have were you bombarded with questions from the nurse assessing you? I know in my past experience when I had visited the doctor the nurses would ask me very random questions or make me fill out questionnaire where I simply would briefly read the questions and keep circling no because none of the questions pertained to me at all. Some of these questions would include do you ever feel alone, or do feel depressed. I always wondered why they would ask me this when my main purpose for my visit was to get a physical exam or a TB shot for my nursing vaccinations. Not until attending nursing school did I understand why nurses have to ask these questions about out health, lifestyle, and mental health. These questions specifically target those who may be battling a mental illness if circling yes to any of those questions such as depression.
Besides just questionnaires the nurse beings the assessment once the patient enters the room. This is where the nurse introduces herself and starts to create a nurse-client relationship. In nursing especially it is important to create a strong trusting relationship with your patient from the beginning so that they feel comfortable with you treating them. For example, would you feel comfortable being treated by a nurse who is rude, talks over you as you try to explain your primary reason for coming to the clinic? I know I certainly would not feel comfortable and would feel like I am being rushed so that they can get to the next patient waiting to be treated. After the nurse and patient establish this relationship, the nurse then begins the second part of the assessment without the patient knowing. As the patient voices other concerns, the nurse is both listening and looking at the patients appearance as to if they are dressed appropriate to the weather, what their posture is like, what facial expression they show and their tone of voice. All of these observations play an important role and could help the nurse throughout the assessment. Did any of you know that the nurse makes note of such things? I know I did not until this year after my health assessment course.
The nurse will then as the name of this assessment starts off start assessing the patients head. Such assessments include a hearing, vision and cranial nerve tests. To test for hearing nurses use the Rhinne. The Rhinne test assess for air and bone conduction in the human body. The nurse simply strikes the tuning fork and places it on the mastoid bone, once the patient can no longer hear the sound at that location the nurse then holds it by the patient’s ear until they can no longer hear...