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VITAL SIGNS & HEAD-TO-TOE EXAMINATION
[Minor updates done on 09-Feb-2012 evening, after simulation lab review.]
Patient assessment is a very important skill for RNs in BC. RNs need to assess every patient at least once every shift.
During the SEC, there is a role-play segment. You will probably need to do a "head-to-toe" examination of your patient. With some practice, it would take around 5 minutes. Add another 5 minutes for taking vital signs, it would be around 10 minutes for the basic assessment. Here's a fictitious scenario. Note: The dialogue is important as the SEC assessment is not only about your nursing skills but your ability to use English in a nursing setting.
Nurse Joy knocks on patient's door.
Patient: Please come in.
Nurse: Good morning. My name is Joy. I am the nurse taking care of you today. How would you like me to address you?
Patient Mary: Hello, Joy. You can call me Mary.
Nurse Joy: Well, Mary, could you tell me your date of birth please?
Patient Mary: 8th of February, 1980.
Nurse Joy: Could I check your ID band please?
Nurse checks the ID band to ensure that it's the right patient. If the patient's reply is right, patient is Oriented x1 (to person).Nurse Joy: Mary, tell me, how are you feeling today?
Nurse asks question to build rapport and also note if patient has any complaints. Note: Nurse also observes the general status of the patient. E.g. Alert, drowsy, in bed, sitting on chair, skin colour, looks pale, looks flushed, etc. Also note any devices hooked to the patient. E.g. IV, oxygen, chest tube, urine catheter, etc. Any mobility aids: cane, walker, wheelchair. Any other personal stuff: reading glasses, dentures, valuables on bedside.Patient Mary: I don't feel so good because I didn't sleep well yesterday night. I kept waking up because I have this headache that just wouldn't go away.
Nurse Joy: I see. How would you rate your pain on a scale of 0 to 10? 0 for no pain to 10 for extremely painful.
Patient Mary: Maybe about 3?
Nurse Joy: Ok. I will check your medications later to see if you have anything that may help with it. Is it alright if I do some health checks with you now?
Note: Pain is part of the vital signs. Since patient's pain level isn't extreme, we can proceed with the examination and return to it later.Patient Mary: Oh, will it take long?
Nurse Joy: It will only take about 10 mins.
Patient Mary: Ok.
Nurse adjusts height of bed to comfortable working level, i.e. no need to bend to assess patient. Nurse Joy takes the vital signs. Note: Remember the normal range for each of these. Temperature (remember the normal range for various routes), blood pressure, heart rate (radial pulse for 15sec if possible. If pulse is regular, x4 for a 1-min count), respiration rate (observe for 15sec. If breathing is regular, x4 for a 1-min count). At each stage, the nurse should inform the patient what she/he is about to do before starting, so as to cue the patient.Nurse: I'm going to check your temperature. Open your mouth and put this under your tongue.
Nurse: I'm going to check your blood pressure. Please lend me your arm. The cuff will tighten and then loosen against your arm, ok?
Nurse: I'm going to check your pulse. Please lend me your hand.
Nurse: I'm going to check your oxygen level. I will clip this to your finger. is that ok?
Nurse clips SpO2 probe on finger, checks the SpO2, and then removes the probe.Nurse: I'm going to check your breathing. Please breath normally.
Nurse: You mentioned earlier that you have headache. When did it start? And can you describe how it feels?
Patient: Well, it started yesterday night. It's a throbbing pain.
Nurse: What makes it worse? What helps to ease it?
Patient: It feels worse when the overhead lights are on. I don't know what may ease the pain.
Nurse notes down the qualities of pain: Location, strength, characteristic (e.g. throbbing), when it started, what worsens pain, what reliefs pain, impact on daily activities (e.g. interrupts sleep).Nurse: Thank you for informing me. Shall I continue with the rest of the examination?
Nurse: Do you know where you are?
Patient Mary: In the hospital.
Nurse: What's today's date?
Patient Mary: I don't know. Wednesday or Thursday? 10th of February?
Note: Neurological assessment. If patient is oriented to person, time, and place, then patient is ORIENTED X3. If not, then, it is x1 and x2 for giving 1 or 2 of 3 correct answers respectively. As for the date, give a 1-2 days allowance for error.Nurse: I am going to shine a light to check your eyes. Look straight at me.
Nurse uses 1 hand cover the other eye (or use the hand as a divider, just above the nose, to block the light on the other eye). Then shines light in each eye.Nurse: Ok, I'm going to listen to your heart and lung sounds. If you feel uncomfortable at any point, please let me know. Is it ok if I lift your gown for it?
Nurse: Take deep breaths in and out.
Nurse lifts the patient's gown to auscultate for heart sounds. See here for the 4 percordial locations to auscultate. And click here for the locations to auscultate the anterior lung sounds.Nurse: I'm going to listen to your abdomen for bowel sounds next.
Patient: What are bowel sounds?
Nurse: It's the sounds made by your abdomen as it digests food. Shall I proceed?
Nurse mentally divide the abdomen into 4 quadrants using the umbilicus, a.k.a. belly button, as the landmark. Then listen to all 4 quadrants. Normally there will be bowel activity in all 4 quadrants. You will need to listen more than 5 mins before concluding that there is no bowel sound in a specific quadrant. Nurse covers the patient anterior with gown.Nurse: Have you gone to the toilet this morning?
Nurse: When did you last pass urine? And pass motion?
Patient: I peed and pooped yesterday night before going to bed.
Nurse: What did your stool look like?
Patient: Like lumpy toothpaste.
Nurse: Is that your normal?
Patient: Yes, I usually go once every 2 days and my stools are usually lumpy.
Nurse to note elimination information.Nurse: I'll check your hands now. Can you squeeze both my hands?
Nurse holds each of patient's hands in his/her own hands. Instructs patient to them simultaneously. Check for strength and whether it is balanced on both sides. Then nurse check the fingers for capillary refill (should return to pink in less than 2 sec). Followed by checking the quality of radial pulse on both sides simultaneously. They should be in-synch, and equally strong and regular.Nurse: I will need to check your breathing from the back. Please can you sit up?
Patient sits up.
Nurse to auscultate for posterior lung sounds. Nurse can adjust the head of bed upwards if patient is not strong enough to sit up on his/her own. Note: Depending on situation, sitting up may be contra-indicated for the patient, e.g. neck spinal surgery patients. Adjust your assessment accordingly.Nurse: Thank you. You may lie down. I am going to check your feet and legs next.
Nurse palpates for dorsal pedal pulse and posterior tibial pulse on both feet. In addition, check for capillary re-fill to the toes. This is to ensure that there is circulation both feet. Followed by pressing onto the fleshy areas above the ankles for edema pitting rating. Nurse places one hand on the dorsal side of each foot.Nurse: Can you pull your toes to your nose against my hands?
Patient does so.
Nurse places each hand on the ventral side of each foot (i.e. the sole).Nurse: Can you push against my hands by as if you're pressing on the brakes?
Patient does so.
Nurse places each hand on each knee.Nurse: Can you lift up your knees against my hands?
Patient does so.
In each of the above, nurse to note the strength in each leg, and whether it is equal bilaterally.Nurse: Ok, we are done with the assessment. Do you have any questions or requests?
Patient: Yes, I would like to order something soupy instead of normal meals today. My headache is affecting my appetite.
Nurse to note addition impact of pain on patient's activity, i.e. reduced appetite. Nurse passes the call-bell to patient, ensures that the top 2 bed-rails are up and the bed is set back to the lowest height for patient safety.Nurse: Ok, Mary, I will change your meal order for you. If you have further questions or need any assistance, please press the call-bell for assistance. I will revert to you regarding your pain medication in a few minutes.
Patient: Ok, see you later.
Nurse exits room.
Summary of head-to-toe assessment. Here's a short list of items to check and the normal results.
- In's and Out's (to chart under each corresponding body system): E.g. Oxygen running at 2L/min on NP (nasal prong). E.g. NGT in-situ. E.g. IV in-situ, running NS at 100cc/hr (Note also redness, edema, ecchymosis, discharge of IV site). E.g. Foley (catheter) in-situ, drained approximately 300cc of clear urine. E.g. Ostomy in-situ, with small amount of liquid brown stool and flatus++.
- General questions and observation (Neurological). Patient alert and oriented x3 (i.e. person, place and time), i.e. A+O x3.
- General questions and observation (Psychosocial). Note the patient's mood, affect and any psychosocial issues.
- General questions and observation (Activity). Note the patient's activity levels. E.g. ADLs (sat in chair, sat in bed, walked along corridor), mobility, sleep.
- Eyes (Neurological). PERL (pupils equal and reactive to light) or PERRLA if accommodation is tested (pupils equal, round, reactive to light and accommodation).
- Lung sounds (Respiratory): Respiration easy and regular. Clear air entry (A/E) throughout lung fields. No adventitious sounds noted.
- Heart sounds (Cardiovascular). Apical pulse strong and regular, no extra sounds.
- Abdomen (Gastrointestinal): Abdomen soft and round, no discomfort. Bowel sounds present in all quadrants.
- Arms and legs (Cardiovascular): Bilateral radii pulses strong, regular and equal. Pedal pulses present bilaterally. Capillary refill < 3 sec on all extremities. Skin pink, warm and dry to touch. That is, Colour Warmth Movement and Sensation (CWMS) satisfactory on all extremities. Note edema, if any.
- Arms and legs (Neurological): Bilateral hand grips strong and equal. Both feet dorsiflex and plantar-flex against resistance. Bilateral knees lifted against resistance.
- Urine/Stool (Genitourinary): Patient up to bathroom to void independently. Last voided ..., last bowel movement ...
- Skin: Note any cuts, breaks, sores, etc. Size and colour. For incisions, note REEDA (Redness, Edema, Ecchymosis, Discharge, Approximation) and COCA of discharge (colour, odour, consistency, amount). Describe dressings, if any.