Video instructions and help with filling out and completing Why Form 5495 Assessment

Instructions and Help about Why Form 5495 Assessment

This is cereth registered nurse or en comment in this video I want to be performing a nursing head-to-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 head-to-toe 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 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 head-to-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 auscultate except you're gonna change it up a little bit whenever you're going over the abdomen you're going to inspect auscultate percuss and then palpate and the reason that you're going to auscultate 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 auscultate get a baseline of what we can here and then we will perk us 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 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 head-to-toe assessment is that okay with you okay then proceed and look at their arm bands so what while you're doing this this is gonna help you make sure you have the right patient and you're gonna be testing them to see if they know who they are their date of birth and ask them some other questions to assess that neuro status so say your first and last name for me first name is being last name is Dover okay and your date of birth a 2882 okay and do you want me to call you Ben or mr. diver why do you have everything okay so then 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 okay and who's the President of the United States Donald Trump okay so he answered all those correctly and he's alert and he's oriented times four he knew who he was he's 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 Maureen at times for 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 zero just hand with zero being no pain at all intending the worst pain you've ever had 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 point 5 or less that's underweight or if it's greater than 30 that is obese now why you been doing all that asking me 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 I just hated are they drowsy what's going on with him do they look their stated age does his skin color match his ethnicity is he does he understand my questions or does 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 I'm more maladies like an amputation any masses lesions it's his skin sweaty cold and clammy do you notice any sign oh so it's right off the bat also do is his hygiene good and it says posture good and you notice any normal smells but during all that 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 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 Bell's palsy or in stroke and we're also just looking at the eyes and the ears or they have the same level and while we're here we're gonna go ahead and look at the facial expressions and test cranial nerve seven which is the facial nerve so can you close your eyes tightly for me and open them up okay now smile for me frown and pop out your cheeks okay and he did that with E so that cranial nerve is intact next what we're gonna do is we're gonna palpate the head the cranium we're gonna check for any masses indentations look for skin breakdown any