Head to Toe Assessment: The Quick Version A full physical head to toe assessment is completed upon admission and at the start of each shift. The focus is on vital assessment parameters, tracking changes from shift to shift and should take no more than 5 minutes to complete. Several activities in the assessment can be completed at the same time. Usually, it is individualized to fit the client’s condition, diagnosis and level of acuity.

Step 1: Evaluate the client’s level of consciousness, eye contact and responsiveness, color and texture of the skin, any IVs, dressings or tubes visible. Ask appropriate questions to determine orientation to time and place. Establish the nurse-client relationship at this time.

Step 2: Assess vital signs. While taking the client’s pulse, feel the skin temperature and moisture. Check bilateral radial pulses. Observe for edema in face or neck. Individualize the assessment: for example, with a neurological condition, check pupils.

Step 3: Remove client’s gown or raise the gown. Use the stethoscope to listen to heart sounds, apical pulse and breath sounds bilaterally. Observe breathing patterns, symmetry of chest movement, shape of chest, and depth of respirations. Check for skin turgor.

Step 4: Auscultate abdomen for bowel sounds. Use palpation and percussion techniques only if appropriate to diagnosis. Palpate bladder if necessary (based on output). If catheter is in place, observe urinary output for color, odor, consistency and amount.

Step 5: Assess lower extremities for warmth, color, moisture, and presence of pedal and popliteal pulses, muscle tone and sensation. Assess for pedal edema or general edema in the lower extremities. Check traction or casted areas for skin breakdown, alignment and placement.

Step 6: Have client turn onto side or sit at edge of bed. Assess posterior lung fields and symmetry of chest movement with inspiration. Assess skin for pressure areas, particularly coccyx and heels when client returns to side-lying position. Evaluate client’s ability to move in bed.

Head to Toe Assessment: The Long Version Neurological Assessment: The neurological assessment starts with the initial contact with the client. Evaluation of verbal responses, movement, and sensation is carried out throughout the examination. In addition, functions of the cerebrum, cerebellum, cranial nerves, spinal cord, and peripheral nerves are assessed. The level of consciousness is the most sensitive and reliable index of cerebral function. Subjective Questions:

1. Evaluate verbal responses to questions around time, person, place and purpose. 2. Ask questions around sensations like pain, itching, burning, tingling or numbness. 3. Ensure that client’s mood is appropriate to situation, is able to follow commands,

and long/short term memories are intact.

Objective Assessment: Normal Abnormal

1. Level of Consciousness: • Awake • Alert • Appropriate Mood • Responds to verbal commands • Answers questions appropriately • Speaks clearly • Orientated to time, person, place and purpose • Recent and remote memory intact

• Drowsy • Difficult to awaken • Unable to give date, month, place • Irritable • Memory deficit • Difficulty finding words • Does not recognize family

2. Motor Responses: • Eyes open

• Eyes closed • Does not follow directions

• Follow commands to stick out tongue, squeeze fingers, move extremities • Responds to painful stimuli

• Does not localize or withdraw from pain • Assumes decorticate posturing (legs extended, feet extended with plantar flexion, arms internally rotated and flexed to chest) May be due to lesion of corticospinal tract • Assumes decerebrate posturing (arms stiffly extended and hands turned outward and flexed, legs extended with plantar flexion) due to lesion in midbrain • Assumes flaccid posturing/no motor response; may be due to extreme injury to motor area of brain • Involuntary movements: tremors, spasms, seizures

3. Pupil Assessment: • Size of pupil: 1.5-6 mm • Shape of pupils: round and mid-position

• Sluggish: early warning of deteriorating condition • Unilateral dilation: sign of 3rd cranial nerve involvement • Bilateral dilation: sign of upper brain stem damage • Unilateral dilation: sign of increased intercranial pressure or compression of 3rd cranial nerve • Mid-position and fixed: sign of midbrain involvement

• Equality of Pupil: Equal • Reaction to Light: (using penlight in darkened room, open eye being tested, cover opposite eye): Pupil constricts promptly • Light Reflex: (both eyes open, shine light in one eye only, observe opposite eye): both pupils constrict • Accommodation: (ability of lens to adjust to objects at varying distances): Lens can adjust

• Pinpoint and fixed: opiate effect • Unequal: sign that sympathetic and parasympathetic nervous systems are not synchronized

Head and Neck Assessment: The names and the regions of the head come from the bones that form the skull. Knowing the names of the bones and regions of the skull can assist in describing the location of physical findings. The brain is made up of three sections: the brain stem, cerebrum, and the cerebellum. There are 12 cranial nerves and 31 pairs of spinal nerves with dorsal and ventral roots. The brain stem is divided into four sections: A.) The diencephalons which includes the thalamus (that relays sensory impulses to the cortex) and the hypothalamus (which regulates the autonomic nervous system, stress response, sleep, appetite, body temperature, water balance and emotions), B.) The midbrain (responsible for motor coordination and eye movements, C.) The pons (controlling involuntary respiration) and D.) Medulla (contains cardiac, respiratory, vomiting and vasomotor centers).

The cerebral hemispheres have and outer layer of gray matter, called the cerebral cortex. The two hemispheres are divided into four major lobes. The frontal lobe controls emotions, judgments, and motor function. The parietal lobe integrates general sensations; interprets pain, touch and temperature sensations. The temporal lobe contains the auditory center and sensory speech center. The occipital lobe controls the visual area. The cerebellum coordinates muscle movement, posture, equilibrium, and muscle tone.

Cranial Nerves and Their Function Cranial Nerve

Function Testing Cranial Nerves

I Olfactory Sensory nerve Recognizes odor in each nostril separately

II Optic Sensory nerve: conducts sensory information from the retina

Demonstrates visual acuity

IV Trochlear

Motor nerve controls the superior oblique eye muscle

Moves eyes to the right, up and down then left

V Trigeminal

Mixed nerve with three sensory branches and one motor branch: the ophthalmic branch supplies the corneal reflex

Demonstrates normal facial sensations

VI Abducens Motor nerve: controls the lateral rectus muscle of the eye

Moves eye laterally

VII Facial Mixed nerve: anterior tongue receives sensory supply, motor supply to glands of nose and palate, supplies muscles of expression and closes eyes

Elevates eyebrows, puffs cheeks, recognizes tastes

VIII Acoustic Sensory nerve: hearing and semicircular canals

Hears whispers with each ear separately

IX Glossopharyngeal

Mixed nerve: motor to parotid gland and sensory to posterior taste buds

Gag reflex at back of tongue

X Vagus Mixed nerve: motor branches to pharyngeal, laryngeal, thorax and abdomen. Sensory to ear, thoracic and abdomen

Same as IX

XI Accessory Motor nerve: innervates the trapezuius muscles

Shrugs shoulders

XII Hypoglossal Motor nerve: controls tongue muscles Sticks tongue out in midline

Subjective Questions:1. Inquire about their eyes and visual abilities? Do they require any aids to see?

2. Inquire about their ears and earring abilities? Do they require any aids to hear?

Objective Assessment: Normal Abnormal

Eye Assessment: • Note visual acuity: observe ADL’s—should perform adequately

• Age related macular degeneration, near and farsightedness

• Note any lesions: No lesions should be noted • Equality of eyelid movement: should be equal in movement • Discharge: No discharge • Pupil size and reaction: should be the same

• Small plaques can indicate lipid disorders • Paralytic drooping of the upper lid • Thick discharges can be conjunctivitis • May indicate neurological trauma or deficit

Ear Assessment: • Ask if they hear normal sounds as you make them: should have no difficulties • Note any external lesions: No lesions should be noted • Discharge: should have no discharge from ear

• Deafness, ringing of ears or buzzing could be caused by ototoxic drugs • Battle’s sign: may be sign of basilar skull fracture • Redness, swelling and pain can be infection • Cerebrospinal fluid discharge indicates head injury

Nose Assessment: • Structural changes: able to breathe regularly with mouth closed • Discharge: should only have minimal discharge

• Obstruction to breathing can be due to deviated septum, swelling of tissues or excessive secretions • Cerebral spinal fluid indicates trauma

Mouth and Lip Assessment: • Note any lesions: should have no external lesions • Note any internal lesions:

• Can indicate dehydration, fissures, pressure sores • White patches can indicate

should have no internal lesions fungal infection (Candidiasis)

Neck Assessment: • Note any lesions or swelling: can have occasional small, mobile non-tender lymph nodes

• Enlarged, tender, immobile nodes

Chest Assessment: Assessment of the chest includes lungs, breasts and heart. External aspects should be observed including symmetrical movement, posture, shape of breasts and axilla area along with internal components of lungs and heart. The lungs extend from 2 to 4 cm above the third clavicle to the eighth rib at the midline. Posteriorly the lungs extend from the third spinous process to the tenth process and on deep inspiration to the twelfth process. Ensure when auscultating breath sounds to alternate from left field to right field as you work your way down. Examination of the chest usually proceeds from posterior to anterior with the client in the upright position. Ask the client to breath a little deeper than usual through their mouth rather than nose since this can produce extra sounds that mask true lung sounds. The heart is located directly behind the sternum, with the left ventricle projecting into the left chest. The action of the heart should be assessed both proximally and distally. Proximal assessment involves evaluating heart sounds, heart rate, and rhythm to obtain information about the mechanical activity of the heart. Distal assessment involves evaluating the peripheral pulses to obtain information about the effectiveness of the heart’s pumping action. One method to assess heart sounds is to start at the aortic area, move slowly across to the pulmonic area, down to the tricuspid area and over to the mitral area. The most important thing to remember is to use a consistent method to compare the different sounds.

Examples of heart and lung sounds can be heard at: http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds/

Breast assessment should include observing for lumps, drainage, dimpling of breast tissue and asymmetry. Any changes that the client indicates should also be noted. Subjective Questions:

1. Ask questions around breathing, exercise and tolerance. 2. Ask if they have any problems with their circulatory system. 3. Inquire about medications currently in use.

Objective Assessment: Normal Abnormal

Respiratory Assessment: • General shape: straight spine, relaxed breathing, level shoulders, ribs that slant downwards • Note respiratory Rate: 12-20 resp/min • Auscultation: No extra sounds heard—symmetrical areas should be the same in quality and intensity

• Breathes sitting forward (emphysema), uses accessory muscles (respiratory distress), curvature of spine, horizontal ribs (COPD), bulging interspaces during exhalation • Increased rate may be due to fever, injury, surgery or trauma to chest wall • Crackles (due to sudden opening of closed airways), wheezes (air passing through narrowed airways), rhonchi (low-pitched rumbling heard on inspiration/expiration-may be cleared with coughing) Absent Breath sounds—may indicate atelectasis, pneumothorax or pleural effusion Faint Breath sounds—may indicate hypoventilation, early atelectasis and COPD

Heart Assessment: Auscultation • Mitral Valve sound: heard best over left, fifth

• Heart sounds not heard in the area (e.g., with left ventricular

intercostal

space and medial to midclavicular line: S1 heart sound (combination of mitral and tricuspid closer) • Tricuspid valve sound: heard best at intercostals space, left sternal border: S1 heart sound • Aortic Valve sounds: heard best at second intercostals space, right sternal border: S2 heart sound (combination of aortic and pulmonic closure) • Pulmonic Valve sounds: heard best at second intercostals space, left sternal border • Heart Murmurs: heard between heart sounds—produced by atypical flow of blood through the heart: faint sound can often be heard in children and young adults

hypertrophy, mitral sound moves laterally) • Sounds altered with aortic stenosis (thrill) and hypertension (accentuated sound) • Accentuated with pulmonary hypertension • S3: Ventricular Gallop: heard best just after S2 at the apex or lower—almost always signifies heart failure in client over 40 • S4: Atrial Gallop: heard just before S1, at the apex, occurs when blood flow from atrial contraction meets increased resistance in ventricle—Normal finding in elderly with hypertension • Can be faint or loud: Present in older clients with heart disease

• Peripheral pulses: radial, brachial, femoral, popiteal, dorsalis pedis, posterior tibial: Easily palpated, strong bilaterally, posterior tibial weaker than femoral

• Difficult to palpate • Unequal pulses • Weak pulse • Absent pulses

The Gastrointestinal and Genitourinary Systems: The abdomen extends from the diaphragm to the pelvis and contains two body systems the gastrointestinal and the genitourinary systems. The gastrointestinal system begins at the mouth and consists of the esophagus, stomach, small and large intestines and the associated organs including the liver, pancreas and spleen. This system has two major functions of digestion and distribution of nutrients and elimination of wastes. The urinary tract consists of the kidneys, ureters, bladder and the urethra. The urinary tract should be assessed frequently and accurately because of changes in urine production reflect changes in other body systems. The easiest way to assess the urinary tract system is to note the quantity and quality of the urinary output. External male genitalia include the penis, the scrotum and testicles. External female genitalia include the vulva, the urethral orifice and the vagina. Subjective Questions:

1. Ask if they have any abdominal pain or discomfort. Noting the location, intensity and if it is constant can help to determine which systems are affected.

2. Establish what their bowel routine is. Information on frequency, constipation, diarrhea and use of laxatives or elimination aids are required.

3. Nutritional issues such as appetite, food intake, swallowing or chewing difficulties along with weight loss or gain should be noted.

4. Assess for the presence of urinary urgency, nocturia, frequency, incontinence or burning while voiding. The color and volume of urine should be assessed.

5. If pertinent ask if they experience genital itching, lesions, discharge, painful or swollen tissue and for women review their menstrual cycle.

Objective Assessment: Abdominal assessment is best done while patient is lying flat in bed. Inspection and palpation of genitalia can be done while assisting patient with personal care or toileting.

Normal Abnormal

Abdomen: Inspection: Client lying flat in bed • Contour of Abdomen: abdomen flat from chest to pubis • Skin Appearance: no change in skin color around umbilicus • Circumference: place tap around largest circumference, draw two lines (top/bottom): No increase in abdominal circumference

Auscultation: Bowel sounds: place stethoscope firmly on right lower quadrant and count sounds for 1 minute—rotate to all quadrants to assess • Bowel sounds gurgle about 5-30 per minute • More sounds can be noted before and after eating

• Concave contour: due to inadequate nutritional intake or inadequate food absorption • Distended: caused by gas and fluid accumulation due to decreased peristalsis, hemorrhage or intestinal leakage post trauma (surgery or auto accident) • Scars, stretch marks, dilated veins, presence of hernia • Abdominal circumferences increasing steadily within 1-2 hours may indicate hemorrhage or ascites • Increased sounds: due to blood in GI tract, diarrhea, or partial obstruction • Hypoactive sounds may be quiet and infrequent due to

• Will be absent initially post surgery—with general anesthesia sounds will return in 1-2 days and abdominal surgery they will return within 3-5 days

Palpation: Client lying flat in bed and mouth breathing, place your hand flat on abdomen with four fingers together and depress 5 cm, palpate all quadrants to assess organs contained within • Soft pliant musculature when relaxed • Coughing does not produce pain in abdomen • No bulges or masses felt

peritonitis or paralytic ileus • Absent sounds can indicate complete obstruction or systemic illness • Rigid muscles can indicate inflammation or infection • Pain with cough can indicate peritoneal inflammation • Masses can be felt with colon disease, vascular aneurysm, distended bladder or cancer

Urinary Tract: • Visually inspect the external urethra: orifice is pink and moist, clear with minimal discharge • Urine output: assess quantity, color, odor, specific gravity and pH of urine. Output should be 1200-1500ml/24 hours or 30-50 ml/hour—should equal oral and IV intake • Clear, yellow-amber color

• Burning or pain may indicate infection • Increased output can indicate increased intake, diuresis, diabetes mellitus or antidiuretic hormone response. Frequent small amounts of output can indicate retention or infection • Decreased output may indicate dehydration, renal failure, or excess ADH response • Cloudy can indicate infection, dark amber can indicate

• Slight odor • Specific Gravity: 1.003-1.030 • Blood: check for blood using hemastix: no blood should be present • Bladder Distention: Not normally palpated • Pain: Assess for pain—should be no pain

dehydration, dark amber to green can indicate hepatitis or jaundice • Foul-smelling may indicate infection, or drug ingestion • Specific gravity >1.030 can indicate dehydration, constant specific gravity of 1.010 regardless of intake indicates renal failure • Blood can indicate infection • Distended bladder accompanied by discomfort and urge to void indicates retention • Severe pain in the flank region can indicate kidney infection or stones

Genital Assessment: Male: Visually inspect the skin for lesions, discharge and cleanliness • Clean, no odor, no discharge, no lesions • Noting groin area: no bulges in groin • Testicles: gently palpate each testicle for size, shape and consistency: two testicles in scrotum, no nodules, no swelling or tenderness

• Unclean, odor, lesions/discharge can indicate venereal disease or cancer • Bulging on straining can indicate hernias • Mass in scrotum: indicates possible hernia, hydrocele, tumor or cyst

Female: Visually inspect the skin for lesions, discharge and cleanliness • Clean, no odor, no discharge, no lesions, no signs of sexual abuse • Assess for lesions/discharge: minimal, clear discharge, menstrual flow, no lesions, no pruritus

• Pain indicates inflammatory disease, unclean, can have musty odor (with bacterial infection), bruises, welts or swelling can be noted with abuse • Thick, yellow, white, or green discharge can indicate trichomoniasis, curdy discharge can indicate candidiasis, lesions can indicate syphilis/herpes or venereal wart

Anus and Rectum: While examining the perineum the perianal and sacrococcygeal areas can also be inspected. • Smooth uninterrupted, intact skin • More pigmented than surrounding skin • Moist and hairless

• Lumps, rashes, inflammation, lesions can indicate infection • Internal hemorrhoids can be seen by asking patient to bear down • Bleeding can indicate tumor or infection • Rectal pain can indicate abscess or infection

Skin Assessment: Initial skin assessment and grading is completed on all patients at the time of admission using the Braden Scale for Predicting Pressure Sore Risk (PHC-EL029). Skin assessment can be incorporated into other parts of the physical assessment, but it is important to ensure that all areas of the body are checked. Pressure ulcers occur predominantly over bony prominences, and excess moisture often causes breakdown in the buttock, inner thigh, and groin areas. Patients with any of the following could be at risk for skin breakdown: decreased sensory perception, increased moisture on the skin, decreased activity, decreased mobility and

decreased nutritional intake. In addition the presence of friction or shearing on the skin, a history of pressure ulcers and any disease process that impairs blood flow/perfusion also increases patient’s risk for developing a pressure sore. Subjective Questions:

1. Does this patient have a history of pressure ulcers, nutritional impairment, diabetes or heart disease?

2. Is the patient mobile and active? Is there increased pressure or shearing that can occur due to lack of mobility?

3. Is increased moisture noted on the skin (ie: incontinence, diaphoresis, weeping edematous legs)?

Objective Assessment:

• Uniform hydration • In dark-skinned people, redness is often not noticeable, but can feel hot or warm to touch • Areas of diffuse redness may indicate cellulites • Area of blackened tissue—necrosis • Moist or wet skin—especially in skin folds and groin area • Dry, flaky skin

Area Specific: Legs and Feet • Smooth skin, hair growth in areas with follicles, healthy toe nails with regular thickness • Normal uniform skin color to lower legs

• Shiny, taunt skin with no hair growth and thickened nail beds is sign of Arterial disease • Hemosiderin staining (brownish areas of staining noted to lower legs sign of venous stasis disease • Atrophy blanche (whitish areas on the skin) is caused by flattened blood vessels and are found around old or current leg ulcer sites

Mental Health Assessment:

The mental assessment is done throughout the physical assessment. It is not generally considered a separate entity. Mood, memory orientation and thought processes can be evaluated while obtaining the health history. The purpose of the mental status assessment is to evaluate the state of psychologic functioning and to monitor safety needs of the client. It is not designed to make a diagnosis but

rather it should provide data that contributes to the total picture of the client at the time of the assessment. Assessment goals should include: collecting data to aid in establishing the cause, diagnosis, and prognosis, to evaluate the state of psychologic functioning, to determine client’s ability to cope with the present situation, to assess the need and availability of support systems and to determine the guidelines of the treatment plan. Initial factors that the nurse must consider in completing a mental status assessment include correctly identifying the client, the reason for admission, history of any previous mental illness, present complaint, any personal history that is relevant (such as living arrangements, history of alcoholism, domestic violence) and support systems available. Subjective Questions:

1. What their admission is for and how long they are expected to be in hospital? 2. Any history of previous mental illness? 3. Any personal history that is relevant such as history of substance abuse or domestic

violence? 4. What support systems do they currently have available to them and do they have

pressing stressors that would worsen by staying in hospital (for example: financial concerns or children to care for)?

Objective Assessment: Normal Abnormal

General Appearance, Manner and Attitude: Physical Appearance: general characteristics, energy level Note grooming, mode of dress, and personal hygiene: appropriate to grooming and dress to situation, age and social circumstance, clean

• Inappropriate appearance, high or low extremes of energy • Poor grooming, inappropriate or bizarre dress or combination of clothes, unclean

Note speed, pace, quantity and volume of speech: Moderate speed, volume and quality of speech Relevance, content, organization of responses

• Accelerated or retarded speech and high quality • Inappropriate responses, unorganized pattern of speech, out of context replies

Expressive Aspects of Behavior: General motor activity: calm, ordered movement appropriate to situation Purposeful movements and gestures: reasonable movements, appropriate gestures Level of Consciousness: alert, attentive, and responsive, aware of time, place and person

• Overactive, agitated or impulsive • Repetitious activities • Disordered attention, distracted, cloudy consciousness, delirious, stuporous

Thought Processes and Perception: Assess coherency, logic, and relevance of thought processes by asking questions by asking about personal history: clear, understandable responses to questions and attentiveness Assess reality orientation to time, place and person awareness: orderly progression of thoughts, awareness of time, place and person

• Disorientated in time, place, person • Disorientated thought forms • Withdrawn, absent mindedness, dogmatic or preaching • Disordered progression of thought: looseness, circumstantial, incoherent, irrelevant conversation • Delusions of grandeur, no awareness of day, time or place

Mood or Affect: Assess variability in mood by observing behavior and asking “How are you feeling right now?”: appropriate, even mood without high variations high to low Assess depth and significance of mood if questioning depression: may be sad or grieving but mood does not persist indefinitely

• Mood swings, euphoria, elation depression, withdrawn • Flat or dampened responses, inappropriate responses or ambivalence

Memory: Assess past and present memory and retention: alert, accurate responses, past and present memory appropriate Assess recall with questions about birth date, age or place of birth: good recall of immediate and past events

• Excessive loss of memory, amnesia, belief in events that never occurred • Poor recall of immediate or past events

Judgment: Assess judgment and decision making ability: ability to make accurate decisions, realistic interpretations of events

• Poor judgment, poor decision making ability, poor choice, inappropriate interpretation of events or situations

Lifestyle Patterns: Identify addictive patterns and effect on individual’s overall health: Normal amount of alcohol ingested, smoking habits, prescriptive medications, adequate food intake

• High quantity of alcohol taken frequently, heavy smoker, addicted to illegal drugs, habitual user of over the counter medications, anorexic or overindulgence of food

Coping Devices: Identify defense-coping mechanisms and their effect on the individual: conscious coping mechanisms used

• Unconscious mechanisms used frequently: repression, regression, projection,

appropriately such as rationalization, suppression,

sublimation or displacement reaction formation, insulation or denial

For video taped examples of assessments go on-line to: http://www.mc.maricopa.edu/dept/d31/nur/learning_objects/_assessment/PhysicalAssessment.html Nursing Diagnoses: Once information is gathered from the head to toe assessment and the various data sources then it can be combined to generate central nursing diagnoses. As the database evolves, patterns of health problems emerge and alterations from normal health states are identified. Nursing diagnoses provides a vocabulary that is used to describe specific nursing practices, research and education. It provides a method to synthesize and communicate nurses’ observations and judgments to all members of the health care team. Surveillance Diagnoses: Surveillance Diagnoses (Meyer/Lavin) is a new term identified to explain and incorporate the extra work that nurses participate in. These diagnoses are based upon the vigilant work performed by the nurse. Vigilance is based on nursing knowledge and is the prerequisite for informed nursing action. It is the backdrop against which professional nursing activities are performed. It is the “watch-ful-ness” that is always part of the nurse’s thinking process as activities are completed. In Meyer and Lavin’s (2005) groundbreaking article, surveillance diagnoses are separated from central nursing diagnoses based upon the accountability of the nurse and the health care team. Central nursing diagnoses such as “ineffective airway clearance” or “self-care deficit” are considered central nursing diagnoses because they reflect the independent nursing practice. For surveillance diagnosis, the nurse is accountable for professional vigilance and the recognition of the problem but is not solely accountable for the interventions or outcomes.

Central and surveillance diagnoses often exist in tandem. For example, if your client is and older adult with poor eyesight and is receiving medication for hypertension then the surveillance diagnosis is “risk for orthostasis”. Nursing intervention includes monitoring blood pressure changes lying, sitting and standing. Information gained would allow the nurse to work with the team (pharmacist/physician) to alter medications if the problem became severe. This client also has a central diagnosis of “risk for falls related to orthostasis”. This calls for independent nursing action to treat with teaching, safety measures and more frequent observation. In the end, the nurse shares responsibility for the management or prevention of the orthostasis, but is independently accountable for preventing falls in this patient. Conclusion: Head to toe physical assessment is one through way in which to gather information in order to systematically assess, plan, intervene and evaluate the care of our clients. By using the consistent terminology of central and surveillance diagnoses helps nurses to describe to others the important work that we do.

Test Your Knowledge: 1. What sources would you utilize to gather information about your patient’s

condition? A. The patient. B. Clinical values and tests. C. Tests, medical history, physical assessment and other health professionals. D. All of the above.

2. What is the 5th vital sign? A. Glasgow’s Coma scale. B. Pain Assessment. C. Peripheral pulses. D. Mental Health Assessment.

3. When is a physical assessment performed? A. Upon admission. B. Upon admission and start of each shift. C. Upon admission, start of each shift and as needed. D. As needed.

4. Which cranial nerve recognizes taste and moves eyebrows? A. Trigeminal nerve. B. Trochlear nerve. C. Facial nerve. D. Vagus nerve.

5. What is the most reliable indicator of cerebral function? A. Level of Consciousness. B. Pupil response. C. Motor response.

6. Faint breath sounds may indicate… A. Normal breath sounds over lower lung fields. B. Atelectasis. C. Pleural Effusion D. B and C.

7. Which statement is true? Atrial Gallop (S4 heart sound) is a(n)… A. Abnormal finding in elderly with hypertension. B. Normal finding in elderly with hypertension. C. Dangerous finding in elderly. D. A and C.

8. What is the correct order of assessment for the abdomen? A. Inspection, Palpation and Auscultation. B. Auscultation, Palpation, Inspection. C. Inspection, Auscultation, Palpation. D. Palpation, Auscultation, Inspection.

9. What is one of the most important pieces of information needed when performing a skin assessment?

A. What their weight is. B. If they have varicose veins.

C. If they have had a history of pressure sores. 10. If your client is overactive, agitated or impulsive they show impairments in….

A. Expressive aspects of behavior. B. Judgment. C. Coping Devices D. Mood or Affect.

Test Answers: 1. D 2. B 3. C 4. A 5. A 6. D 7. B 8. C 9. C 10. A

Glossary: 1. Subjective Data: Information that can only be verified by that person. Examples

would include pain, itching and worry. 2. Objective Data: Information that is detectable by an observer or can be tested by an

accepted standard. Examples of this would include a blood pressure, discoloration of the skin or witnessing crying.

3. Central Diagnosis: A nursing diagnosis as a clinical judgment about individual, family and community responses to actual or potential health problems or life processes. Must be one that the nurse can select a nursing interventions and be held accountable for the outcome. They are termed ‘central’ because they reflect independent nursing practice. Examples include: ‘ineffective airway clearance’, ‘activity intolerance’, ‘self-care deficit’ and ‘risk for falls’.

4. Surveillance Diagnosis: Is a clinical judgment about individual, family and community response to actual or potential health problems or life processes. Nurse is accountable for professional vigilance and the recognition (or diagnosis) of the problem, but is not solely accountable for the interventions or outcomes. Nurse participates inter-professionally, in the ongoing management of the problem. Examples include: ‘risk for hypoglycemia’, ‘risk for hemorrhage’, ‘risk for increased intracranial pressure’, ‘risk for deep vein thrombosis’.