Summary of Head-to-Toe Assessment Nursing | Nursing Physical Health Assessment Exam Skills
The video provides a comprehensive guide on performing a head-to-toe nursing assessment and emphasizes the importance of physical health examination skills. Starting with hand hygiene and patient privacy, the assessment includes checking identification, vital signs, height, weight, BMI, emotional status, skin color, hygiene, and posture. Detailed examinations of the head, eyes, ears, nose, mouth, neck, chest, abdomen, and extremities are conducted, along with palpation for abnormalities, testing of cranial nerves, and auscultation for various sounds. Additionally, the speaker demonstrates the importance of inspecting feet, palpating pulses, checking for edema, assessing capillary refill, testing muscle strength, evaluating reflexes, and examining the back for skin abnormalities. The video concludes by encouraging viewers to explore more nursing-related content on the channel.
### Methodology
1. Inspect feet for ulcers, toenail health, and ingrown toenails.
2. Palpate pulses, including popliteal pulses behind the knee.
3. Check for edema by pressing on the tibia.
4. Palpate pulses on the feet, including posterior tibial and dorsalis pedis.
5. Use a doppler if pulses are hard to find.
6. Assess capillary refill on toes in less than two seconds.
7. Test muscle strength by having the patient push against resistance.
8. Check Babinski reflex using a reflex hammer or finger.
9. Assess the back for abnormal moles, lesions, wounds, and skin breakdown.
10. Listen to lung sounds when the patient is lying on their back.
### Speakers
- Sarah
- Unnamed speaker
Notable Quotes
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38:37
— « Also look at the toenails, do the toenails look healthy or is there fungus or they missing toenails they have a really bad ingrown toenail.
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39:01
— « Assess for that. Next you want to palpate your pulses, we'll palpate the popliteal pulses which are behind the knee.
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40:54
— « Assess the back so whenever you're looking at the back side you're going to look from the head all the way down at the back and you really want to pay attention to any abnormal moles, lesions, wounds, anything like that. »