Head-to-Toe Physical Assessment: Listen & Learn! [Rewind]

 Hey everyone, it's Nurse Melanie. Today I'm bringing back one of the most popular episodes of nursing school, week by week. A full head to toe physical assessment demonstrated on my fiance, well, he was my fiance at the time. Now he's my husband. In this episode, I walk you through each step explaining not just what I'm doing, but why it's important.

Whether you're hearing this for the first time or getting a much needed refresher, mastering a thorough physical assessment is one of the most essential skills for nursing students and for new nurses. It's how we catch subtle changes in our patients. Build confidence in our clinical skills and provide the best care possible.

Before we jump in, I have a quick favor to ask. If you've been enjoying the podcast, it would mean so much. If you could take a moment to leave a review on Apple Podcasts or wherever you listen reviews, help more nursing students find the show, and I would just love to hear what you think. Let's get into it because the more you practice, the more second nature it becomes.

Doing a head to toe assessment is something you'll be doing day in and day out for the rest of your nursing career. So let's learn how to do it quickly and efficiently. First, I'm gonna go over some highly testable information, and then I'm gonna bring you along with me as I give my wonderful fiance a physical assessment.

Now nurses complete an assessment so we can gather both subjective and objective data, make our nursing diagnoses, and then come up with a care plan. You need to know the difference between subjective data and objective data. Subjective data are things that the patient states. The way I remember this is because the S in subjective goes with the S in states for the patient's states subjective data.

This can be symptoms like my head hurts or I feel dizzy. Objective data are things the nurse actually observes. So think O for objective goes with O for observes. Objective data are things like the patient has a fever or the patient just vomited right in front of me. Alright, so what tools do you need to do a physical assessment?

You'll need a stethoscope and a penlight. You'll use the stethoscope to listen to heart sounds, lung sounds and bowel sounds. You'll use the penlight to check the pupils. Now there are usually two sides to your stethoscope. The larger side is the diaphragm, and the smaller side is the bell. You want to use your diaphragm when you're listening to high pitch sounds like breath sounds normal, heart sounds and bowel sounds.

You want to use the bell when you're listening to low pitch sounds like heart murmurs. You're gonna be assessing nine body systems. Those systems are neuro, H-E-E-N-T. This is an acronym that stands for Head, eyes, ears, nose, and Throat. Once again, that's H-E-E-N-T. You'll also be assessing the cardiovascular system, respiratory, gastrointestinal, genital urinary skin mobility, and psychosocial.

And in each system, you'll do things in a specific order. You're gonna inspect first. This means you'll look with your eyes, then you'll palpate with your hands, and then you'll auscultate or listen with your stethoscope. Now, there's one exception to this order. When you're examining the abdomen, you'll look, then listen, and then palpate last.

This is because we want to listen to undisturbed bowel sounds and if we palpated before listening, we'd be moving things around with our hands. Also, we always want to save them more painful procedure for last, and palpating could be painful if someone already has abdominal pain. Auscultating before palpating at least allows us to get that valuable information before they're in pain and maybe refuse to just cooperate anymore.

Alright, so I'm gonna take you with me in just a minute so you can listen to me do a physical assessment on my fiance, but I want to check your understanding. So the way this works is I'm gonna give you a multiple choice question and then I'll pause while you try to answer it. All right. Number one, which of these is an example of objective data?

A, the patient is dizzy. B, the patient has high blood pressure. C, the patient is in pain, or D, the patient tells you they had diarrhea before they got to the hospital. Once again, which of these is an example of objective data? A, the patient is dizzy. B, patient has high blood pressure. C, the patient is in pain or a D.

The patient tells you they had diarrhea before they got to the hospital.

Alright, if you answered B, the patient has high blood pressure, then you are correct. That is an example of objective data because it's something that you, the nurse actually observed. The other examples, the patient is dizzy and in pain or had diarrhea before coming to the hospital. Those are all things the patient stated.

So those would be subjective data. Alright, and the next one, when would you use the belt of your stethoscope? A, when listening to bowel sounds. B, when listening to breath sounds. C. When listening to normal heart sounds or D when listening. For heart murmurs once again, when would you use the bell of your stethoscope?

A, when listening to bowel sounds B. When listening to breath sounds. C. When listening to normal heart sounds or D, when listening for heart murmurs.

And the correct answer is D. When listening for heart murmurs, because heart murmurs make low pitch sounds and the bell of your stethoscope will pick those up a lot more clearly than the diaphragm. Alright, if you got both of those right, good job. If not, that's okay. Better to get it wrong here than on your test.

Alright, so now I'm gonna take you along with me to give my sweet fiance a physical assessment. Hopefully he won't be too silly. My school doesn't include taking vital signs as part of the physical assessment, but just assumes that you've already taken them. So we're gonna assume that someone's already taken his temperature, pulse, respirations, and blood pressure to make your assessment as efficient as possible.

So you want to be inspecting the skin the whole time. You're also constantly assessing the patient's level of consciousness and their ability to follow commands. All right, so I go into the patient's room and I'm already assessing the environment. What machines do they have in the room? Is there an odd smell?

What does the patient look like? Good morning, how are you doing? Thanks for waking me up. Good morning. My name is Melanie, and I'm gonna be your nurse today. I need to do a head to toe assessment on you. Is that all right? I don't have any toes. Is that all right? Yes. All right. I'm just gonna ask you a few questions that we ask everyone who comes to the hospital.

These questions are to see if he's oriented times four. This means does he know who he is, the place, the time, and the situation. Can you tell me your full name, bill Baxter, and your date of birth? 1 1 19 42. Great. And I'm checking his wristband as he tells me this just to make sure I have the correct patient and that he actually knows who he is.

What month is it? September. Do you know where we are? Uh, in the hospital. Why are you in the hospital? I hurt myself. Hmm? Are you in any pain right now? Not currently. All right, that's good. Now, you generally want to work your way down the body from the head to the toes, but there's no set in stone way that you have to do your physical assessment.

If your school has a checklist it uses, then I definitely go by that. But if you find that you need to tweak it a little, then just go for it. Do what feels best for you. I'm gonna walk you through what I like to do. I am gonna start the physical part of the assessment. Now. If you feel any pain, just let me know, okay?

Okay, thank you. So next I get out my pen light. I'm gonna take a look at your eyes. Just look at the tip of my nose. Do you wear glasses? No, I do not. Then I actually look at his eyes before I even turn the pin light on. I'm looking at the sclera, which are the whites of his eyes. I'm looking for any redness or yellowness, um, any drainage or cloudiness in his eyes.

I'm looking to see if the pupils are the same size. Then I'm going to use my penlight to check for Perla. That's an acronym that stands for. Pupils are Equal. Round, reactive to light and accommodation. So I'm, I'm holding the pin light a little off to the side and shining it at an angle into his eye. Both his pupils responded or getting smaller, and I do the same thing to the other eye now to check for accommodation.

I'll have him look off into the distance and then quickly adjust his eyes to something close. Can you look at the top of the wall? Sure. Great. Now look at the tip of my pen. His pupils show. Good accommodation. And open your mouth for me. Uh, I'm using my penlight to look at his teeth and the, the sides of his mouth.

I'm looking for any obvious signs of tooth decay or sores on the mouth. Great. Say ah, again. Uh. Okay, I just saw the uvula, which is the dangly piece that hangs, um, in the back of the throat move up. It should move straight up midline without deviating to one side or the other, which it did. If it didn't, that could be a sign of a neurologic problem.

Alright, tilt your head back. I'm just gonna take a look at your nose. And I am shining a light into his nostrils, checking for any discharge, and I'm checking the patency, which just means are the nostrils open. I'm gonna take a look at your ears. Can you look to the left? Great. I'm looking into his ears with my pen light, looking for any drainage or sores on or behind his ears.

Do you wear a hearing aid? What do you wear? A hearing aid? No, I don't. All right. And look the other way. And I put my pen light back in my pocket when I'm done because I am done using the pen light. Now I'm gonna, I'm gonna look at your head. Now I'm gently feeling around his head looking for any lice or sores.

Have you had any pain or issues with your head, neck, or ears? No, great. I'm gonna listen to your heart, lungs, and belly. Now I'm gonna start with your heart sounds, so just breathe. Normally I put my stethoscope on and pull his gown to the side while still maintaining his privacy the best that I can. I need to get my stethoscope on his bare skin in order to really hear.

What's going on? While I'm working on the chest area, I quickly just pinch under his collarbone. I'm doing that to do a tur test to make sure he's not dehydrated and his skin bounced back quickly, so I know he's hydrated. I'm gonna listen for heart sounds in four spots over the aortic valve. The pulmonic valve.

The tricuspid valve, and the mitral valve. A good way to remember this is with the pneumonic, all patients take medicine. All is for aortic patients. For pulmonic, take for tricuspid and medicine. For mitral, all patients take medicine. And remember, I'm using which side of the stethoscope to listen for normal heart sounds.

That's right, the diaphragm. Now I'm gonna listen to your lung sounds. Take a deep breath when you feel my scope

and I'm listening to 10 spots on his anterior side and it's kind of hard for me to describe where I'm putting the scope, but I'll post some pictures on the website, nursing school week by week.com and you can go there to see exactly where I'm placing the scope on his front and then on his back.

Alright, if you can lean forward for me. I'm gonna listen to your lung sounds in the back. Take a deep breath when you feel my scope. I'm listening to his breath sounds in eight different spots on his back. Some abnormal breath sounds that I'm listening for are crackles, which sound like this.

A whe, which sounds like this,

or a strider, which sounds like this.

All right, you can sit back again. I'm gonna listen to your belly. I am placing my stethoscope in each of the four quadrants on his abdomen and listening until I hear a gurgling sound. If I hear five to 30 sounds within a minute, I can report that his V sounds are normal, active. Anything less than five sounds in a minute would be hypoactive, and more than 30 sounds in a minute would be hyperactive.

If I didn't hear any sounds, I'd have to listen for a full five minutes in each quadrant before I could report that the bowel sounds are absent, and I really hope that doesn't happen because that would be really awkward just to be down there with my stethoscope for 20 minutes. I take my stethoscope off now because I'm done with it.

Alright. I'm gonna palpate your belly. Do you feel any pain? Yes, that hurts. Oh, it hurts right here. Mm-hmm. Okay. Now how would you rate your pain on a scale from zero to 10? It's an eight. Oh, okay. Alright. And now I'm going to assess his arms and his hands. I cross my arms and hold out two fingers on each hand.

Can you squeeze my fingers? Now? Pull me towards you. Oh, and sometimes you may get a patient who thinks he's funny when he tries to pull you down on top of him, and this is why you cross your arms first to make it easier to break the hold quickly if you need to. All right. I'm gonna look at your fingernails.

I'm looking for any discoloration of the nails, and I take this time to squeeze the thumbnails, to check the capillary refill time. The nails will turn white when I squeeze them, but they should return to their normal color within three seconds. I'm gonna check your pulse. I'm feeling his radial pulse bilaterally.

That means I'm feeling it on both wrists at the same time. It feels regular and two plus, which is normal. Can you hold your arms out to the side? Yes, and straight up. And I'm assessing his range of motion. Any pain when you do those movements? No, but my belly hurts. Oh, alright. We'll have someone take a look at that and I'm going to look at your feet.

If he had socks on, I would take them off. I'm checking his pedal Pulse bilaterally, both feet at the same time. I am also squeezing his big toes to check for capillary refill, just like I did on his thumbs. Can you lift your right leg up to my hand? Mm-hmm. And your left. There you go. And can you bend both legs?

Yep. Great. And now just turn away from me. Okay. I'm just gonna take a look at your skin. The sacral area on the tailbone is a common spot to see pressure ulcers, so I'm just checking for any skin breakdown in that area. All right, and one last question. Have you had any pain or burning during urination? Uh, not since Vietnam.

All right, well that's all I need right now. Is there anything I can get for you now? No thank you. Just my belly hurts. Alright. I'll have the doctor come take a look at that. Here's your call light. Let me know if you need anything. Alright, so that's how I do my head to toe physical assessment real quick.

I have one more quiz question for you. When assessing the pupils, what does the A in the acronym perla stand for? Remember, that's Perla. P-E-R-R-L-A Does the A in Perla stand for a active be absent C accommodation, or D appropriate. Once again, when assessing the pupils, what does the A in the acronym, perla, stand for?

A active B, absent C accommodation, or D appropriate? If if you answered C accommodation, then you are correct. Remember, this is when you have the patient look at something in the distance, and then quickly look at something close like the tip of your pen. Okay? I hope this podcast helped give you an idea of what a physical assessment looks like.

If you found this helpful, please leave a review on Apple Podcasts. Just so I know you guys are out there and listening. All right, have a great week and I will talk to you soon.