Before we dive into each specific body system, it’s important to talk about some barriers you might encounter when you start to assess your patient.

Generally speaking, a barrier is something that makes your head to toe assessment difficult or even impossible. There may be certain things on that assessment checklist that you simply can’t assess properly for one reason or another, or things might just be a bit harder and require a bit of a work-around. There could be communication related issues, physiological barriers, or treatment-related barriers. I’m gonna give some examples of each and a really quick idea of how to overcome them, but we’ve added a lot of detail in your outline, so make sure you check that out.

First is communication related – basically this means that for whatever the reason, the patient can’t understand your instructions or you can’t understand their answers. Or maybe you’re trying to show them something and they can’t see it. Language barrier is one of the most common ones you’ll encounter. If you speak different languages, you can’t ask them questions, they can’t understand your instructions, and you can’t understand their answers. So make sure you get an interpreter. One legal note here – for a basic shift assessment, you CAN technically and legally use a family member, but I still say do it at your own risk because you can’t guarantee the questions are asked properly. So I say always get an interpreter! For sensory deficits like blindness – two things happen. One is that if you tried to demonstrate something or say “do it like this” – they cannot see you. You also won’t be able to do a visual field assessment and likely won’t see any pupillary reaction. That’s okay – just document what you DID do. If you have a patient who is deaf, remember that talking louder doesn’t help – but they may read lips, so speak slowly and clearly facing them. But, again – always best to get a sign-language interpreter if they sign. You can also write or use visuals to help guide your assessment. Now, when it comes to communication, we all know from personal experience that if we’re angry or anxious or upset, we don’t want to talk to anyone, we don’t want to answer questions, we don’t want to perform tasks the nurse asks of us. So it is possible that you may have a patient who is just emotionally unable to communicate with you or participate in your assessment. Best suggestion here is to just give them 10 minutes and come back. You can also try to address what is making them upset first, THEN worry about your assessment. It’s all about the patient, okay, so don’t force someone who’s upset to go through your full head to toe assessment.

Next you could have some physiological barriers – physical alterations like amputation and disfigurement might limit what you can assess or the patient’s ability to perform a task. For example, a below-the-knee amputee is not going to be able to do plantar flexion and you won’t be able to get a pedal pulse, right? You may also have a large wound or dressing that prevents you from doing an assessment – like a patient with an open abdominal wound with a wound vac – They’ll have a big foam dressing here in their abdomen and it will be attached to continuous suction – if you put your stethoscope over this, what are you going to hear? Just suction! Right? So the big thing here is – document objectively. Don’t say “bowel sounds absent!” Say “unable to assess bowel sounds due to presence of wound vac dressing”. Don’t say “pedal pulse absent” – Say “unable to assess”. Make sense?

Now the other thing that can cause problems is your confused or altered patient. Of course, you’ll document these specifics in your neuro assessment, but then you may ask them to lift their leg off the bed and instead they touch their nose. So sometimes this confusion means they won’t answer your other questions or do the things you ask them to do. Again, just document “unable to assess due to confusion” or “altered mental status”. Just PLEASE make sure you don’t document that they are alert and oriented and following commands and then say “unable to assess due to confusion” – make sure your charting lines up and is consistent! Don’t get into autopilot!

And of course, if your patient is paralyzed or has some sort of neuromuscular disorder, there are going to be things they can’t do – again, just document objectively. What CAN they do, what CAN they feel? What strength do they have, etc.

Lastly there are a lot of treatments that WE do that can actually make performing a full head to toe assessment a bit difficult. We may chemically sedate or paralyze a patient. Are they ACTUALLY unresponsive? No – they are sedated. Are they ACTUALLY paralyzed? No – it’s drug-induced. So again, just make sure you document these things objectively. We even use specific sedation scales and twitch-tests to determine HOW sedated or paralyzed they really are – so that’s a specialty assessment you may be adding in.

If your patient has a device like a halo or traction – there are going to be range of motion tests you can’t do, there are going to be movements they can’t do. It’s not because they are physically incapable, but just because we have this device in place. So make sure you are clear in your documentation of your assessment that it is device-related. If your patient is intubated, they aren’t going to be able to speak – so they can’t answer your questions and you can’t assess their speech. BUT – what you CAN do is ask them yes or no questions if they’re alert enough and usually they can nod – so just keep that in mind.

And finally, sometimes we have certain restrictions or precautions that make certain assessments difficult – you can just turn a patient on spinal precautions by yourself, but you need to assess their back! So – plan ahead and get help to log roll them! When you do – check their skin, check their butt, listen to their lungs in the back – do everything you need to do while they’re log-rolled, because you won’t be able to do it another time by yourself. We may also have some clients under “Do Not Turn” restrictions – usually because they are too hemodynamically unstable. If that’s the case – document “unable to assess back due to “Do Not Turn” order”. BUT – here’s the kicker – make sure you HAVE an order from the provider!! Otherwise, you will be considered to have neglected part of your assessment – so get that provider to write the order!

Overall, overcoming barriers is really not that difficult, we just have to assess and identify them, implement our work-around and make sure we document everything objectively and accurately.

This is all about patient-centered care – we don’t want to get on autopilot and assess patients like robots. We have to use our judgment and be professional in our assessment and of course in our documentation.
So remember communication barriers are an issue because patients need to be able to understand and process your questions and instructions. Physiological barriers may make it difficult or even impossible to complete certain parts of your head to toe assessment. And treatment-related things like drugs, devices, or restrictions can also make proper thorough assessments more difficult. In ALL of these cases, identify the barrier, implement the work-around, and make sure you document OBJECTIVELY, even if that means saying “unable to assess due to…” whatever it is.

We just know you guys are going to be great at assessing your patients, even when things aren’t perfect. Make sure you check out all the resources attached to this lesson, and dive into the detailed systems assessments. Now, go out and be your best selves today. And, as always, happy nursing!!