SF Nursing Full Body Assessment PART 2

– Okay, welcome back to part
2 of the physical assessment video, next we are going to
assess the lower extremities and then the patient’s back. If you are worried about your
patient rolling out of bed, for safety you do want to go
ahead and raise the side rail back up. And then we are going to
lower the sheets and make sure her gown is lowered. So, in general I’m looking
at the legs, I am looking for any edema, so I do not note any edema. I am also feeling for color
change and temperature changes. So, her feet and legs feel nice and warm. I am gonna go ahead and assess
the pedal pulses, and we are doing that bilaterally
and that is equal and 2+. We also want to assess the
patient’s strength and range of motion so we are looking
at the hip and the knees. So I’m gonna lift up this leg
and I’m just gonna bend that. Okay. Lift up the other leg, perfect,
and can you do that with this leg for me as well?
And the next leg? Perfect. So then also looking at her
feet, I wanna take a look at her toenails and at her toes. If the patient has toenail
polish on you can check cap refill just above the nails. So less than 2 seconds. You do want to go ahead
and check the bottom of the patient’s feet so the bottom
of the ankles, remember all bony prominences you are looking
for any skin break down or wounds and I do not see any
wounds or break down, can you go ahead and lift up with
your feet against my hands? Perfect. And push down
against my hands, good job. Okay, so the patient has full
strength and range of motion in the lower extremities. So
since I touched the patient’s feet I am gonna go ahead
and sanitize my hands again. And if you had gloves on you
would want to go ahead and change your gloves, I am
actually gonna go ahead and put gloves on because I am gonna
assess her back, but then I am going to look at her buttocks
and if you ever are concerned that you might come into contact
with any body fluid or body substances you would want to
have gloves on for protection. So I am gonna put gloves on
because I am looking at your back and then your bottom okay? – [Patient] Okay. – And what I am looking for is just any breakdown in your skin. Okay, can you go ahead, I
am going to lower the bed just a little bit. And if your patient needed
assistance rolling over, depending on their size you
could either assist them yourself or you’d have
another person assist you. Can you go ahead and bend
this knee for me please? Okay and then I am gonna have
you rollover and hold on to that side rail please. Oops, so I am gonna go ahead
and first listen to the patient’s lung sounds and
just keep taking deep breaths in and out. Okay, so when you are listening
to posterior breath sounds you want to make sure that
you are not listening over the patient’s scapula so you start
kind of close to the spine, and for a full inspiratory
and expiratory cycle, in each spot and as you go
down the patient’s back… you would widen out and then
always make sure that you listen underneath the patient’s arm. Okay, your lungs sound nice
and clear and then I am just looking at your skin I can
reassess the back of the patient’s head, and I do not
see any hair loss or skin breakdown, if the patient
had a trach you would want to make sure you specifically pay
attention to the back of the neck, I do not see any
skin breakdown on the bony prominences and then I am
looking at the patient’s back at the coccyx and I do not
see any skin breakdown. This is another time that you
can look at the back of the feet to make sure that you
have assessed them correctly. Okay perfect Miss Greago
you can go ahead and lay back down. How are you feeling? – Good. – Okay, is there anything
I can get for you? – No. – No, okay. I want to make
sure that you have your call light and you know
how to use that, correct? – Mhmmm. – Okay and your IV is still
intact, okay well thank you very much Miss Greago… – So that concludes the end of
part 2 of physical assessment and I hope to see you next time.

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