3.2.2 Head-to-Toe Assessment

Now that you have a new or reviewed understanding of the body processes, you can begin to learn to observe your client for signs and symptoms and learn how to assess the client’s physical status and mental status.  Remember, you are the frontline worker.  You may be the first person or in some cases in care the only person this client sees through the day; therefore, it is important for you to know how to assess your client’s status for changes.

Each day that you see your client you will assess their status to see if there are any changes since your last shift.  Individual assessment pieces may be used to focus on specific areas of concern. This assessment does not need to take long, and over time, it will become routine.

When you approach the client, work through the following sequence in order:

1. Tell them who you are, what your role in their care is and state that you have a few questions to ask them. Do this step even if they are known to you.
2. If they are oriented, ask their name, and where they are. If they have dementia, call them by their name, but do not stress them with other questions they may not remember. Always ask them how they are doing or feeling today.
3. Look at their eyes:
   • Is the white of the eye the same as usual?
   • Is the pupil of the eye large or small?
   • Are the pupils equal in size?
   • Can the client’s eyes follow your fingers as they move side to side and up and down?
4. Ask the client to squeeze your fingers and move their arms and legs. Is the pressure equal or different than your last shift?
5. Focus on their breathing:
   • Does it sound clear?
   • Do you hear sounds or vibrations when they breathe in or out?
   • Are they having difficulty?
   • What colour are their lips?
6. Assess skin colour:
   • Is it pink or pale or grey or yellow?
   • Is it dry, cold or clammy?
   • Are there any new bumps, bruises, bed sores or skin tears?
7. Check the legs:
   • Are they swollen?
   • Can they lift their legs off the bed?
   • Do they raise their legs equally or is one leg weaker
   • Is this normal for them?
8. Do they have any pain? If so, where is the pain? Using the scale of 1-10, is it very low (1) or very high (10) or in the middle (have them give you a number)?
9. Look at the urine output, or ask your client about their urine:
   • Is it dark or pale?
   • Is it yellow?
   • Does it look like there is any particles floating in it?
   • Is the smell strong or not noticeable?
   • Is the amount large or not much?
10. When did they last have a bowel movement?
    • Was it normal for the client?
    • What was the colour?
    • What was the smell like?
    • Did it sink to the base of the toilet or float on top?
11. How do they stand, ambulate or move? Is there a change from their normal movement or activity?
12. Are they tired and weak, or full of energy. Is this their normal?
13. If it is morning or after a nap, how did they sleep?

The key here, as you’ve probably already noticed, is to become familiar with your client’s “normal” and become aware of any changes. Report all changes to your supervisor. Very often, significant health concerns begin very small, and fast diagnosis is key to minimizing severe impacts.

Practice completing this assessment with a volunteer to be comfortable when you are seeing clients.