Putting It All Together: Rapid and Focused Assessment of the Hospitalized Client. This week, you will continue to put the pieces together and gain the skills necessary to complete a concise, accurate, and rapid head-to-toe assessment. You will build on what you have reviewed in the past weeks regarding interviewing, observing, and assessing to gather information.
The rapid assessment requires a minute or less to complete. This is your first encounter with your clients and collection of this data will enable you to prioritize your tasks. Check the client’s identification, and identify yourself. Is the client awake and alert? Observe for any signs of distress, skin color, and assess skin temperature. Observe the client’s response to you. Is the response clear and speech appropriate for age? Document your findings and let the client know that if you must leave you will be returning shortly. Try to give an accurate time frame, such as 15 or 30 minutes.
Bedside Head to Toe
We need to put all of the different puzzle pieces together in a head-to-toe assessment because we typically start at the top and work our way down in a set order, but you can fine-tune or finesse the process to best fit your style and needs. The important part is to have a set way that you conduct assessments each and every time so that you do not miss any steps. Consider what the key is going to be for you. How are you going to approach your head-to-toe assessments so that you consistently obtain all the information you need each time?
Bedside Head to Toe Assessment
Focused Assessment of the Hospitalized Client
Now that you have a systematic approach identified for your basic head-to-toe assessment, how do you make this applicable to the hospitalized client? When you first receive a report, you will want to take a quick peek at each of your clients. Go around and introduce yourself to each of your clients and perform what is called a rapid assessment. In 1 or 2 minutes, quickly scan the client, the room, and the equipment. This big-picture look will help you to determine how to prioritize the full head-to-toe assessment. Take a look at the image and complete the questions that follow.
Questions to Consider
- What is the first thing you should do when you enter the room?
- Based on the picture, what do you believe is the client’s overall level of consciousness?
- Based on the picture above, do you believe that this client is in immediate distress?
- What equipment do you notice in the room that may need the nurse’s attention?
You have completed the process of assessing every major body system. You have learned how to put together a head-to-toe assessment that you can use to gather the information needed to care for hospitalized clients. The systematic approach you have learned will enable you to quickly identify when and where you need to drill down to gain more information.