The Importance Of Head To Toe Assessment

In the first week of the semester, I was very nervous about doing assessments on patients. As I completed a head to toe on the first week I continuously looked at my clinical instructor for feedback and assurance. However, now at the end of the semester I complete all required assessments as appropriate, whether it was a postpartum mom, antepartum mom, labouring mom, a newborn or a gynecology patient.

Describe your thinking when you need to deal with a complex issue, such as writing a major research paper or presenting a staff development workshop.

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

Clinical day started slow, I was a bit anxious about waking my patient up that morning but I knew I had to go in. I woke him slowly and took his vitals and proceeded with my assessment. As I assessed my patient, his wife came in to his room and I introduced myself. During the morning I found out that my patient was being discharged. Before discharge, my patient was going to be fitted for a LifeVest.

Prior to walking in, my expectations for what I was about to partake in and experience were all over the place. I didn’t know whether to expect the absolute worst types of situations going on such as people being rushed into medical rooms or the most basic situations such as patients waiting for a strep throat test. I did expect to see a wide range of patients in terms of race, class, age, and gender. Contrary to the patients, I didn’t expect to see a wide range of race, class, age, and gender within the staff. I expected to see mostly female nurses, and male doctors, majority being Caucasian and middle age. I didn’t expect there to be that much security or any type of possible crime that could go on within a medical facility. I expected the waiting area and facility to be very large, large enough to accommodate a lot of patients at once. Lastly, I expected that taking our field notes would be a challenge because writing notes down in front of patients would be awkward and during interviews it would be hard to conduct a good interview while writing the whole time.

I arrived at clinical 0630 and picked up patient information the morning of. I reviewed all assigned diagnoses, medications, labs, and orders with my assigned students, and we discussed our plan for the day. We both took report from the patient's nurse and then Elizabeth presented at preconference. Kala shadowed the Nurse Lead and I helped Elizabeth with brief changes, pericare, and vital signs. I continued to check on both Elizabeth and Kala throughout the day. Last, lunch and then post-conferance.

I had my first two night shift this week on Sunday 9/13 and Wednesday 9/16. I am on 7 West at Sharp Memorial Hospital and the unit is PCU unit with tele monitoring. The unit had a high census this week, but proper staffing and no codes lead to the nights being relatively calm. I was working with Laura who is not my regular preceptor. She stepped in to work with me for this week while Elle, my regular preceptor, was on vacation. I had a wide variety of patients on my two shifts. The first shift I had a patient that was suffering from an exacerbation of COPD with a history of CHF and a patient that had polycystic kidney disease, which had progressed to end stage renal failure. The second shift I had four patients; one patient had been admitted to the hospital multiple times in the past month for GI bleeds, another patient with a history of diabetes and hypertension was admitted for fever and chills and was later diagnosed with sepsis, the next patient had a history of schizophrenia and was found on the ground in her home and was expected to have been there for over 24 hours resulting in deep tissue injury, and my final patient was suspected to have a history of alcoholism and presented to the hospital with shortness of breath and an oxygen saturation of 89%. The first clinical shift I was shadowing my nurse for a majority of the shift. I was being orientated to the unit and learning where to find supplies on the unit. The second shift I took a

S: How was your clinical experience this week? This week was an okay week. I spent most of my time trying to get back into the swing of things. I was a little rusty at the beginning of the week but it got better as the week went on.

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

Last week Thursday on the orthopedic clinic was a slow but eye opening experience. When I got to the clinic at 8AM, after I was introduced to some of the nurses there, I was immediately assigned to a Medical Assistant (MA) that I had shadow for half of the day. The MA shows me around the clinical and explained her role and responsibility in the clinic setting. During the first several hours, and MA and I were quite busy rooming the patient. Because the MA want me to see how to do thoroughly assessment on a new patient, the MA did a thoroughly assessment and examinations on the first patient we saw. During the assessment, the MA also explained some of the medical procedures to the patient. She did a set of vitals on the patient, particular on new patient, such as blood pressure, height, and weight. We had a total of 15 patients during the morning.

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.

As nurses and future NPs, we have to look at a patient in a holistic manner. If the patient shows signs and symptoms pertinent to only one body system, you would not just look at that particular system. Rather you would conduct a head-to-toe assessment (even just a quick one) to rule out or rule in other diseases and then do a more thorough examination on the system that the patient has specific complaints about.

Upon arriving at Hays Medical Center, my classmates and I met on the third floor for preconference. I grabbed a computer and logged into my client’s chart to see if there were any new orders. I had no new orders. In conference, we were to give report on our patient. My client was a young male in for a bowel resection due to an obstruction. After giving report, I met up with my senior two, Brendell. We proceeded down to the acute floor. I found my client’s room and waited for report from my nurse. I went ahead and introduced myself to my patient and explained to him that I would be helping today, that if he needed anything he should hesitate to ask. I went forward with my bedside assessment, making sure to do everything

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

Today I had a great day at the clinic. For the morning section, I had Omar Lora as my patient. Last time when he came, I collected all my assessment data. Today I updated his medical history, dental history, vitals, and EIOE, then I completed filling out the gingival assessment, the treatment plan, and the SAOP. Finally, I was ready to have my assessment data checked. It went really well, and I learned ways to helped me be more efficient with my time management, for example, I did not know how to have my radiographs up in the other monitor while I was doing my assessments. It was a little time consuming having to open and minimized the window every time I needed to look at the radiographs. Also, I discovered that having a piece of paper out and taking