The Importance Of Head To Toe Assessment

M.C. is a 4 week old Caucasian male and was assessed on 2/3/2015. M.C. was awake and crying in his mother’s arms. He appeared to be well-nourished, well developed and in distress. M.C.’s mother stated his full name and date of birth, which matched his ID band. His mother was sitting in the hospital bed holding him in her arms and attempting to comfort him. His father was laying on the couch in the room. A complete head to toe assessment was not done during this time but the following results were obtained based on a focused assessment. M.C. was on contact-droplet isolation. M.C. had a temperature of 37.2C, his blood pressure was 33/47 with a MAP of 68 taken on his left leg. His respirations were 40 breaths per minute with an oxygen saturation of 100%. His pulse was 178 beats per minute. M.C. was on room air and had a PIV located in his left hand. There was no presence of tubes or drains. Pain was not assessed at this time however, M.C. was fussy and crying. The anterior and posterior fontanels were inspected. The anterior fontanel was soft and flat. M.C.’s lung sounds were clear to auscultation. His mother reported that he had some nasal congestion but had no

It was a really short day for me, so I just worked on completing more referrals and watching Donna check-in patients. There are quite a few steps on Donna’s part that include: checking to make sure that the insurance has not changed, the pharmacy has stayed the same, collecting copay, and a lot more things that I need to still get in there and learn. We had one particular patient that had a procedure scheduled for weeks that we had to reschedule until insurance differences could be worked out. He was not a happy camper, but luckily he directed his anger toward the insurance company and not us. I haven’t got to really be in the front office much this week because of the need in the clinical area, but I hope to get more experience in this area

Roseann. I enjoyed reading your post. Nurses should perform a comprehensive assessment when caring for elderly patients to detect geriatric syndromes. Confusion, dizziness, urinary incontinence, falls, pressure ulcer, and sleep difficulties are classified geriatric syndromes that need special attention. Elderly patients who have acute confusion, weakness, and urinary incontinence should be ruled out for urinary tract infection. I agree diagnostic work-up, vital signs, and thorough head-to-toe assessments are important to evaluate the patient for the underlying cause of the geriatric syndromes. Early identification of the signs and symptoms could prevent complications, decreased mortality, and shorter hospital stay. Using an appropriate assessment

I enjoyed reading your post. I agree that when conducting a comprehensive assessment, it depends on what area of the hospital you work in. I work in the PACU, assessing a patient is much different than when I worked in the ICU. When I worked in the ICU, I would gather the necessary information from the ED and conduct my initial assessment based on prior documentation. I would do a complete head to toe assessment and physical assessment. For example, assessing a patient’s skin completely for pressure ulcers was mandatory. Working in the PACU, our patient usually receives a telephone interview prior to their surgery, which entails obtaining medical and surgical history, medication, support systems, allergies, living arrangements, etc.

Today started off with caring for all hospital patients and preparing the surgeries for the doctor. To prepare for the surgeries I clipped the hair on the leg and put in catheters. Then we sedated and monitored the patient while preparing the surgical site for the doctor. We had two ovariohysterectomies and a neuter today. Once they were done and the clinic opened we immediately had to kick it into high gear when a hit by a car came in. We had to give him some pretty heavy sedatives once he was stabilized so we could do several x-rays which I assisted on restraining and positioning. Once the x-rays were taken, they asked me to develop them by myself. It was difficult to maneuver in that dark room and getting the label in the right spot,

The purpose of this journal is to reflect on my experience and skills gained during my clinical placement at Ben Taub Hospital. On my first clinical day, I was excited and nervous at the same time. My first placement was in the PREOP/PACU area. I was assigned to help a patient who had been in the PACU area going on 2 days. Normally, once the patient comes from surgery they are only in the PACU area for a short period of time before they are discharged home or given a bed in another area of the hospital. This particular patient still had not received an assignment for a bed. The physicians would make their rounds to come check on him daily. The patient was a 28-year-old Hispanic male, non-English speaking, he had a hemicolectomy. He had a NG tube, urinary Foley catheter, and a wound vac. My preceptor had just clocked in and she needed to check on the patient’s vitals and notes from the previous nurse. Once she introduced me to the patient and explained while I was there, she then asked me to check his vitals. (Vital signs indicate the body’s ability to regulate body temperature, maintain blood flow, and oxygenate body tissues. Vital signs are important indicators of a client’s overall health status (Hogan, 2014). I froze for a quick second. I have practiced taking vitals numerous of times and I knew I could do it correctly. I started with the temperature first, when I was quickly corrected on a major mistake I had made by my preceptor. I HAD FORGOT TO WASH MY HANDS and PUT

On April 18, 2016, I attended my assigned clinical site at Maimonides hospital. My assignment consisted of taking care of a 95-year-old female, who I will name as Ms. Lily due to confidentiality. Ms. Lily was admitted on April 9, 2016 for shortness of breath. She is alert and orientated to person, place, and time. She also has a history of atrial fibrillation, diabetes, HTN, and high cholesterol. Ms. Lily was also scheduled to have coronary angioplasty on April 18th.

I found clinical this week more challenging this week than normal. My patient has been in the hospital for a while, however, he was disoriented to his situation. He didn’t remember having an abdominal surgery and thought he was still in the hospital for his back surgery. He also had no energy from not eating properly and wanted to be left alone to sleep. Before the first day of clinical my goal was to focus on teaching. After interacting with him on the first day, my goal for the second day way to try to connect with him and encourage him to take more control of his care.

My progress in planning care for patients is improving. I first do a head to toe physical assessment. I ask about pain and if the patient has any concerns when that is complete. This week the patient voiced concerns about having a bowel movement and rated his pain at a 6 on the 0-10 scale. He also verbalized he wanted to get washed up for the day. I decided to make his need for pain management a priority. I recognized that he was uncomfortable. Before we start any activity, I wanted to wait until his scheduled dose of oxycodone.

Which was really a good experience for me. As usual, my shift included helping the residents with feeding during breakfast and lunch meals. I was able to accomplish some of my goals for the preceding week, which was getting more organized and coming to clinical on time and prepared. My goals for next week are preforming vital signs for some residents and get to know my new assigned resident well. As well as getting to know the other site of the facility well, that I will be working on it the next week. My weakness comes in taking a while when giving a care to a resident. I will work on improving this next week. I am not looking at rushing the residents, but getting quicker and more organize. Nearly the end of the day, I was glad to gain my information about edema as well as watching a video, which was great too. I am looking forward for next week for another exciting day full of knowledge and experience. Overall, I am looking for learning very valuable materials that will be meaningful for me during my

The current practice in my hospital for assessing the level of pain on a scale of 1-10 with 10 being the worst pain is part of the vital sign procedure. The inpatients are asked to rate their pain and are documented in the electronic health record. If the patient says he/ she is in pain, the first step is to detect the characteristics, by asking when the pain started, the area, what make it worse and how strong the pain is and charting the results. In addition a physical assessment- head to toe-will be conducted by means of inspection, auscultation, palpation, and percussion and notifying the provider about the patient’s condition.

Today I felt like I got a sense of the unit, where things are and the general atmosphere. This floor is different from all the others in a sense that there are two patients to take care of and a family to consider as well. Today I had three post-partum patients, two were cesarean sections and the other a vaginal delivery. Looking at the incisions of a caesarian section incision I was surprised by how small the incision was and how quickly it heals. I was anticipating the scars my mother has on her stomach to be like the ones I would see today, but they appear much smaller incision, which shows the progress of caesarean sections over the years. Overall, I found the day to be interesting because all of our patients were in very different places.

How's your new position and weekend going? I would like to express my unhappiness on yesterday 27/6 with Brigitta who was TL. We have 4 Ventilated and 6 non ventilated patients. In the morning, Brigitta asked me to relief Steven, Kulsum and Juicy - all ventilated pts for tea break. I do have 2 discharge patients with 1 required an iron infusion prior transfer. At 11:20 , they all were back and I needed to rush to commence my iron infusion for bed 4. When I assisted my patient from chair to bed with curtain closed, Brigitta came in to the room and asked me to help Kulsum to shower ICU 3 with trachy and ventilator. As I settled Mr Naylon bed 4 then I rushed to help Kulsum and settled the patient in bed 3. Then Brigitta asked me to transfer bed

This past Friday at the Cardiac Catheterization Lab my mentor was not there but I still got to do everything that I enjoy doing, like watching procedures and talking to the doctors, nurses, and staff. When I arrived I knew my mentor would not be there so I had asked another one of the ladies in the office if there were any surgeries that were going on for me to watch. After I was given scrubs to change into I was able to go into where the surgeries are happening. I went into the control room that I was told to go and the nurses and other staff were preparing the patient and setting up the computers and everything they needed before the doctor arrived. The surgery overall was one I have seen before and not as exciting as some of the more unique and different ones that I have seen previously.

This week, my shift at KLH was intense, but at the same time informative. I was able to successfully meet my goal from last week of becoming more fluent with head to toe assessments. I have been finding that regardless of each patient’s acuity, it is becoming much easier to conduct a full assessment without looking at my cheat sheet. Although I was not able to meet my goal of incorporating complimentary and alternative medicine (CAM) into my practice, I was given the opportunity later on during charting to recognize where I could have utilized them. Specifically, my client was experiencing decreased lung sounds on expiration and crackles to her right lower lobe (RLL). In hindsight, I recognize that I could have taken the opportunity to educate on deep breathing or coughing techniques to clear her