How to Perform a Head-to-Toe Assessment
5. Thoracic region:
Assess lung and cardiac sounds from the front and back. Assess them for character and quality as well as for the presence or absence of appropriate sounds. Palpate the chest wall and breasts for any tenderness or lumps.
Listen to bowel sounds throughout the 4 quadrants. Palpate for tenderness or lumps. Palpate the bladder. Ask about intake and output of bowels and bladder. Ask about appetite. Asses genitalia for tenderness, lumps or lesions.
7. Extremities:Assess for temperature, capillary fill and ROM. Palpate for pulses. Note any edema, lesions, lumps or pain.
8. General Questions:Ask the patient how he feels. Has anything changed recently? Any pain, burning, SOB, chest pains, change in bowel or bladder habits/function, change in sleep habits, cough, discharge from any orifice, depression, sadness, or change in appetite?
9. Wash your hands.Document your findings. Report any significant changes or findings to the PCP (primary care practitioner).
10. Evaluate your assessment in terms of The Nursing ProcessWhat You Need:
• Tape measure
• Watch with second hand
• Assessment forms or note paper