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This is Sarah with registered nurse rn.com and in this video I want to be performing a nursing head-toe assessment. This video will be similar to what you have performed in nursing school. Whenever you're doing your clinical check off now, whenever you actually start working as a nurse, you'll be able to tailor this headtotoe assessment to focus on the patient's needs and you'll get a lot faster at this. So, what I want to do is I want to
0:25
cover literally how to assess from the hair on the head all the way down to the toes. So, let's get started. Now, when you're doing your headto toe assessment, you follow that sequence of how you assess each system. So, you start out whenever you're looking at a system, you're going to inspect it, then palpate, percuss, and then oscultate. except you're going to change it up a little bit. Whenever you're going over the abdomen, you're going to inspect,
0:55
oscultate, percuss, and then palpate. And the reason that you're going to oscultate second instead of last, is because whenever you perform palpation, percussion, if you did that before, it could alter the bowel sound. So, we want to go ahead and just oscultate, get a baseline of what we can hear, and then we will percuss and palpate. So, first what you want to do is you want to perform hand hygiene and provide privacy to the patient. Then introduce yourself
1:22
to the patient and explain what you're going to be doing. So, hello, my name is Sarah and I'm going to be your nurse today and I need to perform a headtotoe assessment. Is that okay with you? Yes. Okay. Then proceed and look at their armband. So, while you're doing this, this is going to help you make sure you have the right patient, and you're going to be testing them to see if they know who they are, their date of birth, and ask them some other questions to assess
1:48
that neuro status. So, say your first and last name for me. First name is Ben, last name is Dover. Okay. And your date of birth? 82882. Okay. And do you want me to call you Ben or Mr. Dover? What do you fine? Okay. So, Ben, can you tell me where you're at? I'm at the hospital. Okay. And can you tell me what we're doing here today? Uh head to toe assessment. Okay. And who's the president of the United States? Donald Trump. Okay. So, he answered all of those correctly and he's
2:20
alert and he's oriented times four. He knew who he was. He was able to tell me his name, his date of birth, where he was, what we're doing, and current events. So, we can chart alert and oriented times 4. Then you want to collect vital signs such as the patient's heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and the patient's pain rating. So, Ben, are you having any pain on a scale 0 to 10, with zero being no pain at all and
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10 being the worst pain you've ever had? No pain. Zero. Okay. And I have a video on how to assess those vital signs in depth if you want to watch that video and a card should be popping up so you can access that video. Then after that, what you want to do, you can collect their height and their weight and look at the BMI, their body mass index. Remember, if it's 18.5 or less, that's underweight. Or if it's greater than 30, that is obese. Now, while you've been
3:25
doing all that, asking them these questions, doing their vital signs, you're also before you've even really assessed the system, you are already collecting information. For instance, how is that patient responding to you? What's their emotional status? Are they calm? Are they agitated? Are they drowsy? What's going on with them? Do they look their stated age? Does his skin color match his ethnicity? Is he does he understand my questions or does
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he seem like he can't hear them very well or is there a delay whenever he responds to me or does he respond appropriately and at an appropriate time? Also, do you notice any just outward abnormalities like an amputation, any masses, lesions? Is his skin sweaty, cold, and clammy? Do you notice any cyanosis right off the bat? Also, do you is his hygiene good and is his posture good? And do you notice any abnormal smells? So, during all that,
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you're really collecting all that information. Now, what we're going to do is we're going to start with the head and move our way down to the toes. So, we are first going to inspect the head. And we are looking at the skin color. He it's nice and pink. We're also going to make sure that the head is the same size as how it should be for the body, and it is. And we're looking for any abnormal movements or twitching of the face that he can't control that are involuntary.
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We don't see anything. And we're making sure that the face is symmetrical. There's no drooping on one side. Like in this picture, there's drooping on one side of the face. And this can be seen in Belle's pausy or in stroke. And we're also just looking at the eyes and the ears. Are they at the same level? And while we're here, we're going to go ahead and look at the facial expressions and test cranial nerve seven, which is the facial nerve. So, can you close your
5:24
eyes tightly for me and open them up? Okay. Now, smile for me, frown, and puff out your cheeks. Okay. And he did that with ease. So, that cranial nerve is intact. Next, what we're going to do is we're going to palpate the head, the cranium. We're going to check for any masses, indentations, look for skin breakdown, any infestations. And for this part, I like to wear gloves. So, let's look at the hair. So, what we're doing is we're filling for any masses,
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indentations, and also with this, we're looking for any skin breakdown. And if your patient's immobile, you really want to check the back of the head back here because they're laying on it a lot, and there can be breakdown back there. Also, while you're doing that, look inside the hair. Make sure there is no infestations like lice and there's no abrupt like rounding areas of baldness which could represent alopecia. Then after that since this patient has a beard you want
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to check the beard as well any lesions any infestations or anything like that and just look around. And then once you're done with that what you want to do is you'll do off your gloves and perform hand hygiene. Next, what we're going to do is we're going to find the temporal artery and we're going to palpate them bilaterally. And they are both found right here. And the his are about a two plus. And then while we're right there, we're going to go ahead and
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test cranial nerve five, which is the trigeminal nerve. And this nerve is responsible for many things like mastication. So what I'm going to have you do, Ben, is I'm going to have you clinch your teeth like bite down for me. And I'm going to feel the meter muscle, which is right there. It should be a nice firm ball. And then feel the temporal muscle. Now, what I'm going to do to also test that nerve is have him try to open his mouth against resistance. So, try to do
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that for me. Okay. And he can do that. Now, while we're here, we're going to go ahead and feel the temporal mandibular joint. And we're going to feel right here. And I'm going to have you open and close your mouth. And I'm feeling for any grading or clicking sensations. And I feel none. Then we're going to palpate the sinuses and I'm going to put pressure on these two sinuses right here and you tell me if you feel any pain. Okay. So the max maxillary no and the frontal. No. Next we're
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moving down to the eyes and we're going to inspect the eyes first and we're looking at several things. We're looking at the eyelid. We're looking at the scar which is the wide of the eyes. We're looking at the iris. We're looking at the pupil and we're looking at the conjunctiva. So you shouldn't see any swelling of the eyelids. You should see that the scara is white and shiny. It shouldn't be yellow like in jaundice. And the conjunctiva when you pull down
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the lower lid, have the patient look up. It should be nice and pink. It shouldn't be red. You shouldn't see any drainage or anything like that. Then look at the eyes. How do they set in the eye socket? Is are they equal? For instance, does is there any strabismas? Is there a cross eye where one eye turns in more turns out or up or down? And these eyes are normal. There's no strabismas. Next, you want to look at anoscoria where you have where one pupil would be
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smaller than the other pupil. Are they equal in size? Normal pupils should be 3 to 5 mm in their measurement. And here his are about a three and they are equal. Next what we're going to do is we're going to assess some cranial nerves. We're going to be looking at cranial nerve three which is ocular motor for trocular and then six which is abducins. And we're going to do several tests to check their function. The first one what we're going to do is we're
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going to be looking for any involuntary shaking of the eye called nestagmus. And how we're going to do that is we're going to take our pin light. We're gonna hold it about 12 to 14 inches away from the patient's nose. And Ben, what I want you to do is keep your head still. Don't move your head. And just use your eyes to watch where I move the pin light. And as you're doing this, you're going to do you're going to perform it in the six cardinal fields of gaze. And you're just
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going to move it. And you're looking for any involuntary shaking of the eyes. So here we go.
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Next, we're going to see how reactive the pupils are to light. And to do that, we're going to dim the lights a little bit and we're going to have the patient stare off at a distant object that helps dilate those pupils. And then we're going to shine using our pin light in at the side and we're going to see how that pupil responds. it should constrict and then on the other side it should constrict as well. So say their baseline pupil size was like 3 millimeters, it
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should go down to 1 millimeter and it should happen on both sides. Okay. So Ben, stare off at that object right on the wall over there for me. Okay. And that dilates the pupils and we're just going to shine light in at this side. Okay. Constrict. Constrict. Okay. Dilate again. and then go to the other side. Do the same again. And they both constricted an equal size. Next, what we're going to do is we're going to check for accommodation. And how we do
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that is we turn the lights back on. We just previously had them dim, but we now make it light again. We're going to have him stare off at a distant object that helps dilate the pupils. And we're going to take a pin light. You can use a pin light finger. And you're just going to slowly move it inward to the nose. And what you're looking for is that those pupils constrict. They accommodate and the eyes cross while looking at the pin light. So here we go. Stare off in the
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distance, please. And I don't want you to move your head or anything. Just keep it real still and just follow this pin light. Okay. Ready?
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Okay. So now we can document because we just checked all of the things with the eyes. We can document that the pupils are equal round reactive to lie and the accommodate. So that's where that acronym P E R R L A comes into play. Next we're going to move on to the ears. So first what we do is we inspect the ears. We look on the outside of the ear. Is there any abnormalities, any redness, any drainage, anything like that? And Ben, are you having any pain
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in your ear? Okay. And sometimes if you have patients who've had long-term gout on the helix of the ear, they may have what's called a tophi, which is an accumulation of like a whitish yellowish uric acid crystal on the skin. So if you ever see that, that is what that looks like. Next, we're going to palpate on the ear. We're just going to move it around. And Ben, tell me if you have any tenderness whenever I do that. and any feel any abnormal masses or lesions and
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then move the targets a little bit. Does that hurt or anything like that? No. Okay. So, no pain or tenderness. Then we're going to palpate the mastoid process which is the big hump behind the ear. And we're looking at it. Is it swollen? Is there any redness? And whenever I touch on it being does it hurt? No. Okay. And just see if the patient reports any tenderness with that. Then while you're there, you can use the odtoscope to inspect the
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tempanic membrane. And remember, the tempanic membrane should be a pearly gray translucent color and should be shiny. So for an adult, you're going to pull the pin of the ear up and back. And we're just going to inspect it. And also, while we're looking at that, we are looking at the cone of light. And remember the cone of light in the right ear should be at 5:00 and in the left ear should be at 7:00. Next, we're going to do one more thing with the ear. We're
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going to test cranial nerve eight, which is the vestibular cular nerve. And what I'm going to do is I'm going to include one of his ears and then whisper two words on the other side. He needs to tell me what I said. So, you ready? Mhm. Okay. I'm going to include this one. Apple banana. Apple banana. Okay, very good.
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Cat, dog, cat, dog. Okay, and that nerve is intact. Next, we're going to move on to the nose. And we're going to inspect the nose. We're going to make sure it's midline on the face, which it is. We're going to look at the septum. Is it deviated? Anything like that? And ask the patient, are you having any trouble with your nose? Are you having any drainage or anything like that? No. And you want them to make you want to check the patency of the nose. So then I'm
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gonna have you olude one side of the nostril, breathe out of the other and vice versa. Okay, heard airflow. Air flow nice and patent because sometimes people can have polyps that can block it or the deviated septum. Then you want to take your pin light and you just want to look inside the nose. Look for any drainage, redness, or any like polyp or anything like that. And everything looks clear. I don't see anything. And then we're going to test the olactory cranial nerve one, the sense of
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smell. So Ben, what I'm going to have you do is I'm going to have you close your eyes and I'm going to put something in front of your nose and have you breathe in and smell and you tell me what you smell. And whenever you do this, use something that's pleasant smelling, not something that's really stinky because it could elicit like a gag reflex or something like that if the person has a sensitive nose. Okay. Vanilla. Okay. And this was vanilla
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extract. And that is correct. So that cranial nerve is intact. Next, we're going to move on to the mouth. And for this part, like to wear gloves. And if your patient is coughing and hacking, you might want to wear a mask with a shield so you don't get any mucus on your face or in your mucous membrane. So, first what we're going to do, we're just inspecting the lips. Make sure they're nice pink color. They're not chapped. there's no sores on them. And
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one thing with a lot of patients, whenever their oxygen saturations are low, their lips may turn dusky or blue color. So, you want to make sure they're nice and pink because that can represent our oxygen level. Now, let's inspect the inside of the mouth. But first, let's test cranial nerve 12, which is the hypo glossal nerve. And what I'm going to have you do, Ben, is I'm going to have you stick out your tongue and move it side to side. Okay? And he does that
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with ease. Now, what we're going to do is we're going to inspect the inside of the mouth. You'll need a tongue blade for that. And just open up your mouth for me. And I'm going to look on the inside of the cheeks. Nice and pink. Don't see any sores. You're looking to see if they're nice and pink and there's no lesions or anything like that. And stick out your tongue for me. The tongue should be moist like this and pink. You don't want it to be beefy red, which is
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like an pernicious anemia. You don't want it to be dry or cracked. That could be dehydration. Okay, you can put the tongue in. Then I want you to lift up your tongue for me and look for any lesions underneath the tongue. That's where mouth cancer can hang out. And I don't see any. Okay, you can close. Then um you'll while you're also looking at the gums, open up a little bit. You're going to look around for cavities, any loose or broken teeth, no dental carries
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in there. Then, okay, sort of open up your mouth a little bit more. Put your tongue down. And you're going to look at the soft and hard pallet. Now, while you're in there, you want to look at the uvula. Make sure it is nice and midline. And his is nice and midline. And we're going to test cranial nerve nine, the glossio ferill. And so, what I'm going to do is I'm going to have you say ah. And what you want is that uvula to move up. A. Okay. And then we're just going to
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test the gag reflex. I'm sort of just going to poke a little bit back there and elicit a gag reflex. Okay. There you go. Gag's really good. and um cranial nerve 10, the vagus is intact because he's able to talk with talk to me without horarsseness and he's able to swallow. Then when you're done inspecting the mouth, be sure you take off your gloves and perform hand hygiene. Now moving on to the neck. So what we're going to do is we're going to
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inspect the neck first. So you're going to have the patient extend the neck up a little bit and you're looking at that trachea. Is it midline? Look for any lesions and look for any lumps like what you might see in thyroid problems like a gorder. And we don't see any of that. Then what we're going to do is we're going to test cranial nerve 11, which is the accessory nerve. So Ben, what I'm going to have you do is move your head side to side, up and down. Okay? And then shrug. Try to shrug
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against my resistance. And he does that with ease. So that nerve is intact. Then we're gonna place him at a 45 degree angle and we're gonna have him turn his head to the side. And what we're looking at is the jugular vein. We're looking for any jugular vein distension, JVD. So Ben, I'm going to just turn your head to the side like that. And we're looking for any distension of the vein. And we do not see any. Next, what we're going to do is we're going to palpate. So
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we're going to palpate that trachea just to confirm it is midline. And Ben, do you feel any tenderness or anything like that? Ask him if he feels any tenderness. and I don't feel any lumps. Then next, what we're going to do is we're going to palpate the lint nodes, all sides of those. And Ben, as I do this, tell me if you feel any tenderness. And what I'm feeling for is any hard lumps or anything that may be inflamed. So, what we're going to do,
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turn a little bit this way. And there we go. We're going to start at the pre-uricular, which is right in front of the ears. Then we're going to go to the back of the ears, the posturricular. Then we're going to go to the obipal, the parotted, jugulo digastric. Then we're going to go to the submandibular and then the submental. Then we're going to go to the superficial cervical. And then we're going to make our way down to the deep cervical chain. Any tenderness so far? Then we're going to
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go to the posterior cervical and then right above the clavicle, we're going to go to the supraclavicular and not feel anything and no tenderness. Next, we're going to palpate the corateed artery. And this is one artery that you do not palpate bilaterally. You do one individually. So, we're going to fill on this side. And you're gonna find it next to where the groove of the neck and next to the trachea. And his is nice and bounding. It's two plus. Then we're
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just going to fill on the other side. And same strength. Two plus. Then lastly, what we want to do is we're going to oscultate the corateed artery. And you're going to do one side at a time. And you're going to compare sides. And you're going to listen with the bell of your stethoscope. And we're listening for a brewy, which is a swishing sound. So Ben, what I'm going to do is I'm going to have you breathe in, breathe out, and hold it for me. Okay, go. Breathe in. Breathe out.
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Okay, you can breathe normally now. Did not hear it on that side. Okay, breathe in, breathe out for me, and hold it.
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Okay. And I did not hear a brewy on that side as well. Now, let's move to the upper extremities. So, what we're going to do is we're going to inspect the extremities and we're looking for any lesions, any redness, swelling, and this is a good time if they have a central line, an IV that you look at that, make sure it's not red. Does IV need to be changed? Does that pick line or central line need a dressing change? Assess that. Then you can palpate. And what
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we're going to do is we're going to palpate our pulse, our radial artery. So fill those bilaterally. And they are two plus. And they're equal. Then we're going to check capillary refill. And to do that, we're just going to press down on that nail bed and see how fast it comes back. And it's less than two seconds. Then we're going to check skin tining the skin and see how fast it goes back. And that was good. Then we're just going to look at the range and the motion of
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the fingers and the hands. Look at these joints in the hands. Do you see anything abnormal? Like for instance like herbodine or boards nodes which are found in osteoarthritis and ask the patient are you having any pain in your hands or anything like that? No. Then you can palpate the brachial artery which is found in the bends of the arm and just feel those because that's another pulse site and those are two plus. And just as a side note, if this
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was a patient that was getting uh dialysis and they had an AV fistula, you would want to palpate that and feel for the thrill. Make sure that that is present up in that arm, wherever their fistula is at. Then you want to test the muscle strength. So, what we're going to do is I'm going to have you squeeze my fingers as hard as you can. Okay? Okay, that's really good. Then I'm going to have you push up against my hands and I'm going to push up against your arms.
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Okay. Push. Okay. Very good. Okay. And five plus normal strength. Then we're just going to test his put your hand underneath the elbow and just feel as you move the arm. Do you feel any grading crepitus of those joints? A lot of times in arthritis you can feel that and move that bilaterally. Another thing you want to do with the upper extremities is to check for a drift. And what you will do is you'll have the patient hold out their arms and
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close their eyes. Hold it up for about 10 seconds. And you're looking for a drift like this. So go ahead, do that and close your eyes. Okay? And we're assessing to see if this hand will drift upward. And a lot of times if a patient has had a stroke, okay, you can put them down. Has had a stroke or something like that, you will see a drift. Next, we're moving on to the chest and we're going to inspect the chest. We're looking for any abnormalities like lesions or any
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wounds, anything like that. We're also inspecting the patient's effort of breathing. Is it really labored? Are they using those accessory muscles to breathe? Also, we're looking at that anterior posterior diameter. So, turn to the side like that. And you're looking for that barreled chest. And it will be increased in patients with like COPD. They will have what's called the barrel chest. And now what we're going to do is we're going to listen to heart sounds
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and then we're going to listen to lung sounds. So first let's oscultate heart sounds. And we are going to do this in five locations. And they're based on where the valves are located. And I like to remember the pneumonic. All patients effectively take medicine. And the first letter of each word represents the valve except for effectively. So A would be aortic. P in patients would be pulmonic. Effectively would be herbs point. And this is just the halfway point between
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the base of the heart and the apex of the heart. And there's no valve location there. And then T is for tricuspid. And then M is for medicine. So again using the diaphragm, we're going to listen at the right of the sternal border at the second intercostal space. And that's going to be the aortic valve. So to find that second intercostal space, find the sternal notch. Go down to the angle of Lewis. Then just go a little bit to the right and you're in the second
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intercostal space. And this will be the aortic. And we're just listening. Love dub. Love dub. S1 s2. And s2. The dub is going to be louder in this location. Then we're going to go a little bit over to where the pulmonic valve is found. That's on the left of the sternal border at the second intercostal space. So just right across again just listening to love dub love dub and s2 dub is going to be louder in this location. Then we're going to go a little bit down to the
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third intercostal space and this is herbs point and again you can hear love dub but there's no specific valve here. Then we're going to go down to the fourth intercostal space and this is where the triricuspid valve is and love S1 is going to be the loudest at this location. Then we're going to go to the fifth intercostal space midclavicular line and we're going to listen to the mitral valve and again S1 is going to be loudest here. Dub and
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there's something special about this site. This is the point of maximal impulse. This is where you're going to listen for the apical pulse. So, we're going to set here and we're going to count it for one full minute. And a normal aical pulse in adult should be 60 to 100 beats per minute. And his aical pulse was 63. Then we're going to switch over with the bell of our stethoscope and we're just going to repeat in those locations and we're
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specifically listening for heart murmurs. So that swishing, blowing sound. So that's what we're going to listen to with that.
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and I did not hear any. Now, let's listen to lung sounds. Now, when you're listening to lung sounds, you're listening for abnormal sounds. And here are some samples of some abnormal sounds that you may hear. Crackles.
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Wheezes [Music] a friction rub
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or strider.
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First, we're going to listen anteriorly. And what we're going to do is we're going to listen with the diaphragm of our stethoscope. And we're going to start at the apex of the lungs. And we're going to always compare sides and just inch our way downward and assess all the loes of that right and left lung. So first let's start up here. Okay. And then I want you to take good deep breath in and out. So here we go. Apex. Okay. We're going to compare sides.
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Then we're going to move down to the second intercostal space. And this is going to help us assess the right upper lobe and the left upper lobe. So, another deep breath in and out.
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Then we're going to go down to the fourth intercostal space and we're going to assess where our right middle lobe is and our left upper lobe because remember the right lung has three loes and the left lung has two loes. So, let's listen to our left upper lobe.
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We're just going to go down a little bit more.
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Then we're going to go mid axillary at the s six six intercostal space and we're going to listen to the right and left lower loes. So, you just want to turn to the side right there. Take a good deep breath in for me.
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Okay, other side.
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Okay, now let's listen posteriorly. Again, using the diaphragm of the stethoscope, you're going to start listening at the apex and work your way down. And one thing to keep in mind when you're listening back here, you have the scapula and you don't want to listen over those because you won't be able to hear the sound. So you're going to listen in between where the scapula and the spine are. So down in these regions right here. And again, we're just going
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to compare sides. And you can do this part at the end if you wanted to whenever you turn your patient over to look at their back side, but we're just going to go ahead and do it now. So we're going to start here on the apex. compare sides. Then we're going to find C7, which is that vertebral prominence. It's the big ball right there. You can't miss it. And go down to about T3. And you'll be in between the shoulder blades. And go a little bit in between the shoulder
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blades and the spine right in there. And you're going to assess the right and left upper lobes.
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Then from T3 to T10, we're just going to end to round and we're going to listen to the right and left lower loes.
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Okay, now we're going to assess the abdomen. And remember, we're switching our sequence and how we assess. We're going to do inspection, oscultation, and then percussion or palpation. So, we're going to do oscultation second. So, whenever you're looking and assessing the abdomen, have the patient lay on their back. And what we're going to do is we're going to inspect the abdomen. And first I want to ask Ben, are you having any stomach issues at
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all? No. No. Okay. And when was your last bowel movement? Yesterday morning. Yesterday morning. And how are you urinating? Do you have any pain while you're peeing? Do you have problems starting a stream? Any discharge, anything like that? Nope. It's normal. Okay. And with your um male patients, you want to ask about that due to prostate enlargement with starting a stream. And if he was female, I would ask him when his last menstrual period
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was. And also again, ask the female patient about urinating and things like that. Now, if the patient had a Foley, this is the time when you would want to look at the urine, inspect the Foley, and look at that. Just conglomerate your urinary system and your GI system together. Okay. So, we're inspecting the abdomen. We're looking at the abdominal contour. And this patient's scalfoid. it goes in a little bit. You can also have flat, rounded, or protuberant.
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And also, we're going to know if there's any pulsations. A lot of times in this area right here on thin patients like with Ben, I can see the aortic pulsation in this patient. It's right above the umbilicus and looking at the belly button and checking for any masses. Do we see any hernas or anything like that? Also, if your patient had any wounds, you would want to look at that. And if they had a PEG tube, you would want to assess the site, make sure it's not red,
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and ask them how it feels. And with your osttomies, with your osttomies, you would want to look at the STO and make sure it is like a rosy pink color. It's not a dusky cyanotic color and it's not prolapse. And look and see what type of stool it's putting out. And note that, note the smell. note when if the bag needs to be changed, anything like that. So, now we're ready to listen to the bowel sounds. And what we're going to do is we're going to listen with the diaphragm of
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our stethoscope. And we are going to start in the right lower quadrant and work our way clockwise. And we're going to listen to all four quadrants. And you should hear five to 30 sounds per minute. And if you don't hear any bowel sounds, you need to listen for five full minutes. And you need to note, are these normal? Are they hyperactive or hypoactive? So, let's listen.
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Okay, this is our right lower quadrant. We're going to move up to the right upper quadrant. Move over to the left upper quadrant. and then down to the left lower quadrant
35:13
and bowel sounds are normal. Now, we're going to listen for vascular sounds and you're going to do this with the bell of your stethoscope and we're going to listen at the aortic. We're going to listen at the renal arteries, iliac arteries, and you could listen at the fmeral art arteries if you needed to. So, you're going to listen at the aorta artery and it's a little bit below the zyphoid process and a little bit above the umbilicus. So about right here and
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we're listening for like a blowing swishing sound that which would represent a brewy. Okay. And none is noted. Then we're going to listen at the right and left renal arteries which is a little bit down from the aorta location. So here's the right. Okay. None noted. And then over the left. Then we're going to listen at the iliac. And it's a little bit below the belly button right here. And this is the iliac artery. And then listen on the other side. And again, like I pointed out, you could
36:16
listen at the femeral artery in the groin if you needed to. Now, we're going to do palpation. First, we're going to do light palpation, then deep. And Ben, as I do this, please tell me if you feel any pain or tenderness. So, first we're going to do light palpation. And we'll just start in the right lower quadrant, work our way around. And you're going to go about 2 cm. And you're just feeling for any rigidity, any lumps, masses, anything like that. How's that feel? Feels fine. Okay.
36:52
Okay. Now, we're going to do deep palpation. And we're going to go about four to 5 cm. So, a lot more deep. And again, you're just feeling for any masses, lumps. And Ben, tell me if you have any tenderness. And sometimes you can do this with two hands if need be. If you're not strong enough like me
37:12
feeling anything feels nice and soft. Heard some belly sounds. That's why you do this after you listen because you stimulate it.
37:28
Okay. Everything felt good. Now, we're going to assess the lower extremities. So, first what we're going to do is we're going to inspect. We're going to look at the color from the legs to the toes, making sure it's nice and pink. And here we see that Ben has a little bit of a tan line here. And um we're looking at the hair growth as well. You want to make sure there's normal hair hair growth because in PVD you will see hairless, shiny, thin legs. And here we
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have excellent hair growth. And um also, do you see any abnormal swelling just right off the bat before you've even touched the patient? And look at the legs and the feet for any swelling, redness, swelling. Do you have any pain or anything in your legs, anything like that? And look in the at the joints. Make sure there's no redness on the joints because a lot of times with gout, it likes to start out in the big toe. So, make sure that everything looks
38:18
good. And then on your diabetic patients, make sure you look at the bottoms of their feet because these patients don't have the best feeling in their feet. So their shoes could be wearing on them or they could have stepped on something and not even know it. So inspect those feet. Make sure there's no ulcers or anything that like that that needs to be addressed. Also look at the toenails. Do the toenails look healthy or is there fungus? Are
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they missing toenails? They have a really bad ingrown toenail. So assess for that. Next, you want to palpate your pulses. We'll palpate the papil pulses which are behind the knee and those are about two plus. They're equal bilaterally. I'm just feeling his legs. They're nice and warm. And I'm going to push over his tibia firmly. And I'm seeing if there's any edema. So push there. And if there is edema, a lot of times when you push down, it's like this
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hardike type gel. it will just separate and your finger will leave this indention. And here we don't have any. Now we're going to palpate on the feet and we're going to feel on the pulses. And I'm going to dawn gloves. Perform hand hygiene and dawn gloves. And we're going to feel on the pulses in the feet. We're going to feel on the posterior tibial and two plus really good. And then we're going to feel the dorsalis pedus which is on top of the foot. two plus with that. And if you can't
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ever find these, because sometimes these are hard to find in patients, you can get a Doppler if you have one on your floor. Next, I'm going to check the capillary refill on his toes just like how we did with the fingers by pushing down and less than two seconds. Check the other one.
40:12
Okay, now I'm going to have him push against my hands. Push against my hands, Ben. Okay, good job. Now, I'm going to have you raise your legs against resistance. Good job. Now, we're going to check the Babinsky reflex. And you can use your reflex hammer for this and use the end of it, or you can use your finger if you don't have that. And what we're going to do is we're going to take this up through the ball of the foot and curve it. And we're looking for the toes to
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curl in, which would be a negative normal response. So, let's check that. Okay. Okay. And that was normal. Then, we're going to do our gloves and perform hand hygiene. And next, we're going to assess the back. So, whenever you're looking at the backside, 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, and assessing for skin breakdown, especially on your
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patients who are mobile. So that would really be concentrating on in the backside area on the coxix because that's where a lot of breakdown happens and on the back of those heels if you couldn't see it whenever you were assessing the feet. And also you could, if you hadn't already, you could listen to the lung sounds as you have the patient over on the back. Okay, so that wraps up the nursing head to toe assessment. Now, please be sure to check
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out my other videos because I have a lot of Inlex review videos to help you study for INLEX along with other nursing skill videos, career tips, and everything you need to succeed in nursing school all the way to becoming a nurse in your profession. So, thank you so much for watching and please consider subscribing to this YouTube
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