The responsibility of a registered nurse is to collect a patient’s physical and mental health status. They also need to collect a patient’s social status information, so the nurse can identify the patient’s needs. While preparing the future-care plan for a patient, a nurse should consider the patient’s past health history and all the essential aspects of patient care; in that way, a nurse can develop good communication and understanding with the patient. A nurse needs to collect all the authentic information about the patient and provide the best treatment and nursing care. A nurse needs to follow the nursing assessment methods to access the patient’s information. It is necessary to perform a head-to-toe assessment proficiently to collect patient data. After this assessment, the next step is a diagnosis which is performed after a clinical judgment is passed. This is followed by a diagnosis being made, and then nurses make healthcare plans according to findings and set the health goals and specific duration to achieve those goals (ANA, 2021).
Nursing Head to Toe Assessment
A professional nurse will perform the head-to-toe assessment, a baseline examination to determine the patient’s condition. There are four steps of a nursing head to toe assessment:
- first is inspection,
- second is palpation; a nurse palpates with hands to check any abnormal masses,
- the third one is percussion; it is a method of physical examination a nurse will tap a body part or joint through an instrument, and
- the fourth is auscultation; it is a method in which, through a stethoscope, a nurse will check the heart and lungs’ sound.
A basic nursing Assessment is followed by these four steps mentioned above (Registered Nurse RN, 2018).
According to nursing ethics, a professional nurse introduces them to the patient by maintaining a professional, friendly environment and, collect the patient’s details and information which is helpful in diagnosis (Clinical Guidelines Nursing Melbourne, 2021). After performing the primary assessment, a nurse will examine the patient from head to toe; starting from the head, a nurse will review the face and hair to check if the patient’s facial features are regular and symmetrical. A nurse will also examine the eyes to check if there is any infection or if the eyes are pale, indicating jaundice. Then a nurse will check and palpate if there is any abnormal mass in the head or any infestation like lice in hair. After that nurse will check the ears for any abnormal appearance or tophi and air wax, and in the same way, a nurse will examine the nose and mouth. After that, a nurse will move towards the neck to check for any abnormal appearance, like a goiter. Moving on, the nurse will examine hands to check joint deformities and palpate to check nodes in hands. After that, a nurse will inspect the chest for any breathing or respiratory distress; then, a nurse will gradually move forward towards the abdomen till toe. Many abnormalities are detectable during the inspection because of their visibility, for example, facial drooping.
Nursing Assessment Importance
The nursing assessment plays an impertinent role in the patient’s well-being. For a nurse, it is the initial step to identify the patient’s problem and healthcare needs. Accurate nursing assessment can identify the patient’s problem, and a nurse can bring a significant positive change in a patient’s health outcomes by performing nursing assessment properly and making the diagnosis after clinical judgment.
Nursing Assessment Process
A nursing Assessment process collects and analyzes a patient’s physiological, psychological, spiritual, and economic status and the patient’s health history. There are four steps for nursing head-to-toe assessment 1. Inspection 2. Palpation, 3. Percussion 4. Auscultation, after performing all the steps, a nurse can make clinical judgment and patient’s healthcare plans.
Nursing Assessment of an Unconscious Patient
It is challenging for a nurse to assess an unconscious patient; a nurse will have to apply the following components:
- Glasgow Coma Score to check consciousness level,
- check breathing patterns,
- observe eye moment and pupil reactivity,
- look for signs of motor responses, and
- diagnose the reason behind unconsciousness (Nickson, 2020).
ANA. (2021). The Nursing Process. Retrieved from https://www.nursingworld.org/practice-policy/workforce/what-is-nursing/the-nursing-process/.
Melbourne, T. (2021). Clinical Guidelines (Nursing) : Nursing assessment. Retrieved from https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/#Introduction
Nickson, C. (2020). Examination of the unconscious patient. Life in the Fast Lane. Retrieved from https://litfl.com/examination-of-the-unconscious-patient/
Registered Nurse RN. (2018). Head-to-Toe Assessment Nursing. Retrieved from https://www.registerednursern.com/head-toe-assessment-nursing/