Head to Toe

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The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems. In preparing for the assessment, it is important to explain the purpose of the assessment, explaining why it is important, informing the patient of what the nurse will intend to do, and how the patient can help, knowing that there can be possible pain or embarrassment upon assessing certain areas. The purpose of the nursing assessment is to gather information about the patient’s health so that the nurse can plan individualized care for that patient. The nurse must inform the patient that all information gathered is kept confidential based on the HIPAA (Health Insurance Portability and Accountability Act). This basically means that only those health care providers who have a reasonable need to know will have access to it. While interviewing the patient, it is important to build a trusting relationship or positive rapport between the nurse and the patient. This relationship will decrease the stress the patient may have in anticipating what is about to be done to him. The patient then will be much more relaxed and cooperative if you explain what will be done and the reason for doing it. The nurse is then to prepare the environment of unnecessary external stimuli by appropriately arranging the curtain and closing doors as well as to provide privacy for the reason being that most people are embarrassed if his or her body is exposed to the public...
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