Nose to Toes

This is how you perform a nose to toes secondary assessment as a paramedic, nurse or doctor. It should be noted that before a nose to toes secondary assessment is performed a primary assessment including ABCD should be first performed.

To complete a thorough nose to toes assessment you should assess the following from the head down (generally because the head is just about the most vital part of the body and tells you most things).

Head: look at the person’s head to see if there are any abnormalities, colour differences, contusions, swelling. Gently run your hands (with gloves on) over the hair from the front through to the occiput (back of the head). Then examine the eyes, nose, mouth and ears for signs of bleeding or CSF leakage (cerebral spinal fluid). Ask the patient to gently clench his or her teeth and run their tongue around their mouth to see if there is any bleeding. Assess the eyes. Have a look with a pen torch and assess the eyes to see if they are equal, reactive to light, and document the size of the pupils (this may indicate many things, such as adrenaline, opioid drugs, etc in the system).

Neck: Feel the neck and assess for pain, discomfort, or any defformity.

Chest: while gently feeling the rib cage with both hands ask the patient to take a deep breath. Watch for any signs of discomfort, such as grimacing, or difficulty taking a deep breath. Make sure to note where it hurts, if it hurts. Expose the chest so that you can clearly see if the chest is expanding symmetrically or asymetrically (as in the case of a flailed segment of the rib cage). Be careful if you are a man assessing a woman here (okay, even if you are a woman assessing a woman, you better be careful about this – and alway try to keep them modest). Assess for respiratory rate and the effort of that rate. Look to see how deep the patient is breathing – is it shallow or deep? Now use some equipment. That stethescope that makes you look like a doctor. Use it to assess the breath sounds. A normal breath should be heard by using a reasonable stethescope, and should sound like air softly moving in and out. Assess any abnormal sounds, such as wheezes, crackles, absent breath sounds or stridor. Now assess whether these sounds change if the patient takes a deep cough? Or, if the sounds are heard on the inspiratory phase or the expiratory phase? How well can the person speak? Can they speak a full sentence, only short phrases, single words, or nothing at all? How anxious do they appear? How distressed do they appear?

Abdomen: Expose the abdomen and gently palpate each of the four primary quadrands of the abdomen. Assess for guarding, regidity, tenderness. As with all other pain assessments, assess for OPQRST (see pain assessment). Assess for fullness. If it appears distended, ask if this is normal.

Pelvis: Gently feel the pelvis and ask if there is any pain. In Australia, we no longer “spring” the pelvis to assess if it has been fractured. This is because there is the risk that you will make the pelvis much worse if they do happen to have an open book pelvis fracture.

Motor/sensory: Assess the motor sensory results of all four limbs. Ask the patient to squeeze your hands. Feel for equal or unequal strength. Squeeze each hand individually afterwards, and ask them to tell you which hand you have just squeezed. Ask them to push down and pull up with both feet. Again, assess for an equalness or unequalness to the strengtha and ability. Expose the feet and assess their sensory response by apply gentle stimulus to each individual foot.

Back: If still unsure if the patient has had a spinal injury, log roll the patient onto their side, and expose the back. Gently palpate the spine, from the upper cervical region down to the lower lumber region. Assess for the continuity of the bones in the spine. Look for obvious deformity or contusions. This is an important part of a noes to toes assessment of a patient. I have made the mistake of taking a patient into an ED without assessing their back (because I was too concerned with the injuries to the patient’s legs. However, when they rolled the patient in the ED they found a large branch penetrating through his back. It wouldn’t have changed my treatment of him, but it would have made me look like a more competent paramedic when I gave my handover to the resuscitation team in the ED.

Final Assessments: if you are satisfied that the person does not have a spinal injury and they are capable of standing up, assess their abilty to walk. Watch to see if they favour one side or the other. If they appear to have trouble, ask if this is normal or new?