Nursing is all about critical thinking! Whether you are starting your shift or have a few minutes to act, you have two decisions to make: whether you go for a full head-to-toe examination or just a focused assessment. Head-to-toe nursing examination and focused assessment in nursing are two essential tools of a nursing toolkit, and mastering both of them is essential for nurses. nurses should know when to use head-to-toe nursing assessment and when to use focused assessment.
What is the difference between a head-to-toe nursing assessment and a focused assessment?
Both are essential for nurses, but nurses should know when to use a head-to-toe examination and when to use a focused examination or assessment. The main difference between head-to-toe examination and focused examination is as follows:
Head-to-toe examination
Head to toe examination is a systematic, comprehensive and full body examination that includes both physical and mental status of the patient. This examination is done from top (head) to bottom (toes), covering every part of the body.
Purpose of head-to-toe examination:
The purpose of a head-to-toe assessment is:
- To get the initial and comprehensive information about the patient’s current health.
- Identify actual and potential health issues of the patient.
- Detect signs early in the patient.
- Monitor changes over time in the patient.
When is the head-to-toe assessment performed?
Head-to-toe assessment is a detailed assessment of the patient and is performed during the following times:
- During the admission of the patient.
- Annual checkups.
- Nurses should perform a head-to-toe examination at the start of the shift, especially in acute care.
- before and after any procedure or surgery.
What is done in a head-to-toe nursing assessment or examination?
The following is done in a head-to-toe examination:
- General appearance that includes mood, hygiene, posture, etc.
- Vital signs such as heartbeat, breathing, etc.
- Neurological status, such as level of consciousness, motor response, speech, etc.
- HEENT examination, which means Head, Eyes, Ears, Nose, Throat, etc.
- The respiratory system, such as lung sounds, breathing, etc.
- The cardiovascular system, such as heart sounds, peripheral pulses, etc.
- The gastrointestinal system, which includes bowel sounds, abdominal tenderness, etc.
- Musculoskeletal system checkup that includes mobility, range of motion, etc.
- Skin checkups, such as color, temperature, wounds, etc.
- Psychosocial observations that include behavior, mood, etc.
Focused assessment
Another type of important assessment that is done in nursing is focused assessment. In the focused assessment, one specific area or problem of the body is checked. For example, if the patient says that she has pain in her chest, then nurses will not go for a whole-body assessment; instead, they will focus on the heart and lungs to find out what the problem is.
Purpose of focused assessment or examination:
- As the name indicates, focused assessment is done to focus on a specific area of concern, for example, if the patient is complaining about chest pain, then the nurses focus on that area only.
- To check the previous issue to see if it is getting better or not, for example, by checking the wound every day.
- Focused assessment is also done to check if the medication is working or not, for example, to see if the sugar level is low after insulin.
When is focused assessment performed?
- Focused assessment is done during routine assessments.
- Focused assessment is also done during emergencies.
- Clinical settings such as home health, urgent care settings, etc.
What are the examples of focused assessments?
Some of the examples of focused assessment or examination are as follows:
- Patients with shortness of breath, then nurses will check for lung sounds, respiratory rate, etc.
- In cardiac-focused assessment, if the patient has complained about chest pain, then the doctors will assess heart sounds, blood pressure, skin color, etc.
- If the patient is complaining about abdominal pain, then the doctor will focus on an abdominal-focused assessment and will ask about bowel movement, appetite, etc.
How long does it take to do a head-to-toe assessment?
It takes about 15 to 30 minutes on average to perform a head-to-toe examination, but time can vary depending on the experience of the doctor or if any other abnormalities are found.
How long does it take to perform a focused assessment?
It takes about 5 to 15 minutes on average to perform a focused assessment, as in this assessment, the nurses or healthcare providers only focus on a specific area of the body.
What is a head-to-toe physical examination or assessment?
A head-to-toe physical examination or assessment means examining the patient’s physical body from head to toe. This includes everything, for example, eyes, ears, abdomen, chest, head, etc.
Conclusion
The two most important assessments in nursing are head-to-toe examination and focused assessment. Nurses should know which one to perform when. In head-to-toe examination, nurse’s asses every area of the patient’s body by starting from head and all the way to toes. It takes about 15 to 30 minutes on average and includes the physical and mental status of the patient. In focused assessment, nurses and healthcare providers only focus on one area of the body that patients are complaining about. For example, they check the wound area every day to see if it is healing or not. Focused assessment takes about 5 to 15 minutes, but time can vary.
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