Chapter 2: Patient Assessment
2.5 Head-to-Toe / Systems Approach to Assessment
Critical Thinking Exercises: Questions, Answers, and Sources / References
Critical thinking questions are in bold type, and the answers are italicized. Additional resources or references are provided below.
- Consider why having a systematic approach to assessment might be important.
A systematic approach helps to provide the nurse with an overall understanding of each patient. This might happen when the nurse first meets the patient (for example, when the patient is admitted to the unit or at the beginning of a shift) and when prompted by a change in patient’s health status.
2. Identify two situations where a focused priority assessment might be more appropriate than a full head-to-toe assessment.
- When a patient is in a crisis situation, such as respiratory distress or chest pain, it is important that the assessment be focused, the correct diagnosis made, and the patient treated.
- When detailed information about a specific body system is necessary; for example, nursing a patient with gangrene will need specific understanding of the patient’s integument and cardiovascular health.
Source:
Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2017). Clinical nursing skills and techniques (9th ed.). Elsevier; Mosby.
Sample Learning Activities
- Faculty present learners with different patient scenarios, and ask them to brainstorm which systems require focused assessments. To encourage critical thinking, ask learners to provide rationales for their decisions.
Possible scenarios:
- Joey. Age 8. Fell off of his bike, hit his head, and lost consciousness for approximately 30 seconds.
- Tilley. Age 79. Is at the clinic with concerns about urinary frequency and burning with voids.
- Nga. Age 23. Twisted her ankle while playing softball. She is in Emerg.
Possible resource:
The Royal Children’s Hospital Melbourne. (nd). Nursing Assessment. https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_assessment/
2. Faculty present learners with a case study, and ask them to map out a head-to-toe assessment as if preparing to assess the client. To encourage critical thinking, ask learners to provide rationales for their decisions. Discuss as a large group.
Possible case studies:
- Gino. Age 78. Lives in extended care and has dementia. Has a history of type 2 diabetes and hypertension. You are the RN responsible for completing the monthly head-to-toe assessment and documentation.
- Belle. Age 43. Has arrived to the nursing unit from the recovery room following an appendectomy. You are the RN admitting her to the nursing unit.
- Khar. Age 58. Is in the community clinic describing heavy menstrual bleeding and extreme fatigue. You are the RN doing an admission history.