Head-to-Toe Assessment
Unit One
Head-to-toe assessment review
Objective One
Demonstrate head to toe assessment of the
adult client
Physical Examination Techniques
Inspection = observation of the client (may at times include use of penlight, otoscope, and/or ophthalmoscope)
Palpation = use of touch to assess clientUse light pressure first to assess body surfaceNext use deep palpation to assess underlying
structuresAssess areas of pain/tenderness/discomfort last
Percussion = tapping fingers on the client’s skin using short strokes to assess underlying structures to determine size/density/location
Auscultation = use of hearing to assess client
Types ofPercussion and Auscultation
Percussion --Direct percussion involves tapping lightly with
the pads of the fingers directly on the client’s skin
Indirect percussion involves use of both hands; strike the stationary finger like a hammer to produce the best sound
Auscultation --Direct auscultation involves listening to the client
without using an assistive instrument (i.e. wheezing, chest congestion)
Indirect auscultation involves listening to the client with the use a stethoscope
Assessment of 5 Percussion Notes
Flatness = soft intensity, high pitch, short durationHeard over solid areas (muscle)
Dullness = medium intensity, medium pitch, medium durationHeard over fluid-filled areas
Resonance = loud intensity, low pitch, long durationNormal lung sound
Hyper resonance = very loud intensity, lower pitch, longer durationHeard over hyperinflated areas (emphysema)
Tympany = loud intensity, high pitchHeard over air-filled areas (gastric air bubble)
General Survey*Begins at first contact with the client and
continues throughout the exam*Provides an overall impression of the
client/client systemAppearance and behavior
Appears stated ageSpeech/behavior appropriate to developmental
stageFacial expressionsPhysical/emotional distressSkin color
Vision and hearingGlasses, hearing aid, etc
General Survey (cont’d)Speech
Appropriate, logicalTone, speed, and clarityVocabulary/grammar
Body type and postureBody size/buildMobility, gait, and coordinationPhysical deformitiesRange of motion
Dress, grooming, and hygienePoor hygiene/unkemptManner of dress appropriate for climate
General Survey (cont’d)Mental status
Level of consciousnessOrientationMood, affect
Affect is the emotional state as it appears to others. Mood is the emotional state as described by the patient. Observe the patient's facial expression. No part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression. Facial expressions generally are not consciously controlled.
InteractionVital signs
T/P/R and BPPain assessmentAllergies
Height and weightNutritional statusUnexplained weight loss
Skin AssessmentSkin characteristics
Temperature Compare upper and lower extremities, and bilaterally Excessive warmth may indicate fever, whereas
excessive coolness may indicate poor circulation, shock, or hypothyroidism
Moisture Should be warm and dry (but excessively dry skin may
indicate dehydration)Color
Varies per age, culture, ethnicity Mongolian spots = blue-black areas that are sometimes
present on the lower back or buttocks of African American, Native American, and Asian babies
Capillary hemangiomas (‘stork bites’) = small, irregular pink-red areas present around the face/neck of newborns
Common Skin Color VariationsColorColor
VariationVariationDescriptionDescription SignificanceSignificance
Pallor Loss of pink/yellow tones or extreme paleness in light-skinned clientsLoss of red tones in dark-skinned clients
Poor circulation, low hemoglobin levelAssess via oral mucosa, conjunctiva, nail beds, soles of feet, palms of hands
Cyanosis Blue-gray coloration of the skin; ashen
Central cyanosis is R/T hypoxia May be seen in extremities after exposure to extreme cold
Jaundice Yellow-orange cast to the skin
Associated with liver disordersAssess via sclera, oral mucosa, palms and soles
Flushing Widespread, diffuse area of redness
Results from fever, excessive room temperature, sunburn, polycythemia, vigorous exercise
Erythema
A reddened area Associated with rashes, skin infections, prolonged pressure on the skin
Ecchymosis
Bruised (blue-green-yellow) area
Bruising may indicate physical abuse
Petechiae
Tiny, pinpoint red or reddish-purple spots
Extravasation of blood into the skinMay be associated with a disorder or medication
Skin Assessment (cont’d)Skin characteristics (cont’d) --
Texture Should be smooth and soft May be affected by exposure, age, endocrine disorder,
and impaired circulationTurgor
Refers to the elasticity of the skin, and indicates hydration status
Skin that takes 3 seconds or longer to return to its original position is termed ‘tenting’, and indicates dehydration
Lesions Primary = result of disease or irritation Secondary = develops from primary lesions as a result
of continued illness, exposure, injury, or infection Evaluate for size, shape, pattern, tenderness, pain, etc
Skin Nodule--a solid mass extending into the dermis. (2) Tumor--a solid mass larger than a nodule. (3) Cyst--an encapsulated fluid-filled mass in the dermis
or subcutaneous layer. (4) Wheal--a relatively reddened, flat, localized
collection of fluid. An example is hives. (5) Vesicle--circumscribed elevation containing serous
fluid or blood. An example is chickenpox. (6) Bulla-- large fluid-filled vesicle. An example is a
second-degree burn. (7) Pustule--a vesicle or bulla filled with pus. An
example is acne.
Skin characteristics (cont’d) --Edema
Excessive amount of fluid in the tissues Common in congestive heart failure, kidney disease,
peripheral vascular disease, or low albumin levels Pitting edema is graded on a 0 to +4 scale
Assessing Pitting EdemaTrac
eMinimal depression noted when pressure applied
+1 Application of pressure creates a depression of about 2 mm; no visible distortion; rapid return of skin to position
+2 Application of pressure creates a depression up to 4 mm in depth that disappears in about 10-15 seconds
+3 Application of pressure creates a depression of approximately 6 mm in depth that lasts about 1-2 minutes; area appears swollen
+4 Application of pressure creates a depression up to 8 mm in depth that persists for about 2-3 minutes; area is grossly edematous
Assessing the HairAssess for color, texture, condition, and
distributionPediculosis = head lice infestationNits (lice eggs) may be found on the hair shaft
close to the scalpAlterations in hair distribution may be the
sign of diseaseAlopecia = hair loss
Chemotherapy Nutritional deficiencies
Hirsutism = excess facial or trunk hair Endocrine disorders Steroid use
Assess scalp (dandruff, dermatitis, psoriasis, etc)
Assessing the NailsCondition of Condition of Nail/Nail BedNail/Nail Bed
Indications or ConcernsIndications or Concerns
Pale or cyanotic beds
Circulatory or respiratory disorders that result in anemia or hypoxia
Half-and-half nails Appears as a distal band of reddish-pink that covers 20-60% of the nail; caused by low levels of albumin or renal disease
Mee’s lines Appears as transverse white lines in the nail bed; results from severe illness
Splinter hemorrhages
Small hemorrhages under the nail bed that are associated with bacterial endocarditis or trauma
Black nails Related to blood under the nail--occurs after a local trauma
White spots Zinc deficiency
Clubbing Refers to an angle of the nail bed that is 180° or more (normal is 160°); associated with hypoxic states (i.e. chronic lung disease)
Spooning Iron deficiency
Thickened nails Poor circulation or fungal infection
Brittle nails Hyperthyroidism, malnutrition, calcium and iron deficiency
Soft, boggy nails Poor oxygenation
Vital SignsBody temperature
Wait for 15-30 minutes after the client smokes or eats/drinks something hot/cold before taking an oral temperature
RespirationsCount unobtrusively for 30 seconds if respirations
are regular, and for 60 seconds if they are irregular
Observe rate, rhythm, and depth of respirationsBlood pressure
Client should be seated with both feet on the floorClient should be inactive for 5 minutes before
measuringUse correct cuff size, and support the client’s arm
at the level of his heart
Vital Signs (cont’d)Assess apical pulse
Palpate 5th intercostal space at the midclavicular line for stethoscope placement
Count for 60 secondsNote pulse rate, rhythm, and quality, as well
as the S1 and S2 heart sounds
Assess radial pulseMake sure client is resting while assessing the
peripheral pulsePalpate appropriate site, counting for 30
seconds if the pulse is regular, and for 60 seconds if the pulse is irregular
Compare pulses bilaterally
Assessing the HeadObserve symmetry of features, facial expressions
Abnormal facial features may indicate genetic or chronic disorder (i.e. Graves’ disease, hypothyroidism/myxedema, Cushing’s syndrome)
Assess jaw motion for clicking, pain, or crepitus, which may indicate temporomandibular joint syndrome (TMJ)
Measure head circumference if indicatedAcromegaly, a disorder of excessive growth
hormone, may result in enlarged head in adolescents and adults
Microcephaly is an abnormally small head size that may accompany mental retardation
Hydrocephalus may present in infants and children, indicating an accumulation of excessive cerebrospinal fluid
Assessing the EyesExternal structures
PERRLA (pupils equal, round, reactive to light and accommodation)
Conjunctiva: smooth, glistening , and ‘peach’ in color
Sclera: smooth, glistening, and blue-white in colorCornea: transparent, smooth, and moist
Visual acuitySnellen chart measures distance vision
Myopia = diminished distance visionNear vision measured by having client read
newsprint from a distance of 14 inches Hyperopia = diminished near vision Presbyopia = decrease in near vision due to the aging
process
Assessing the EarsOtic structures
External ear = collects and conveys sound waves; protects the middle ear from the external environment Otitis externa = infection of the outer ear that may
result in a painful auricle or tragusMiddle ear = consists of the tympanic
membrane, eustachian tube, and the ossicles; conducts sound waves from the external ear to the inner ear Otitis media = middle ear infection that may present
as tenderness behind the earInner ear = hearing and equilibrium
Cerumen (ear wax) should be present, but should not occlude the ear canalMay be black, dark red, gray, or brown in color
Assessing the NoseSinus areas should be nontender upon
palpationNasal passages should be pink and moist,
and free from drainage or lesionsSeptum should be symmetricalAssess client’s ability to breathe freely
through both sides of the noseSense of smell is diminished in older adults
due to atrophy of olfactory nerve fibers
Assessing the Mouth and NeckBuccal mucosa should be smooth, moist,
and pink:Common Buccal/Oral VariationsCondition of Condition of
Mouth/Oral MucosaMouth/Oral MucosaIndications or ConcernsIndications or Concerns
Paleness Anemia or inadequate oxygenation
Canker sores Painful vesicles that erupt with allergies and stress
Gingivitis Red, swollen or spongy, bleeding gingiva with receding gum lines; tenderness may be present; this is a sign of periodontal disease
Parotitis Inflammation of the parotid salivary gland
Stomatitis Inflammation of the oral mucosa
Leukoplakia Thick, elevated white patches that do not scrape off; may be precancerous lesions
Thrush White, curdy patches that scrape off and bleed caused by a fungal infection
Aphthous ulcers Small, painful vesicles with a reddened periphery and white/pale yellow base; caused by viral infection, stress, or trauma
Mouth and Neck Assessment (cont’d)
Mouth/lips should be symmetricalAssess for swelling or droopingAssess for difficulty swallowing
Assess teeth for dentures, obvious caries, loose teeth
Tongue should be moist, symmetrical, slightly rough, smooth, pink, and freely movableAbnormal findings include deviation from
midline; glossitis (inflammation of the tongue); limited mobility; dry, furry tongue related to dehydration; black, “hairy” tongue associated with fungal infections; swelling, nodules, or ulcers
Palpate neck for tenderness/nodules, thyroidInspect for swelling, ROM
Lung AssessmentAlterations in respiratory rate
Bradypnea = slow respirations (<10 breaths/minute)Tachypnea = fast respirations (>24 breaths/minute)
Alterations in respiratory effortDyspnea = labored breathingOrthopnea = inability to breath in the horizontal
positionAbnormal breath sounds
Wheezes = high-pitched, continuous musical sounds Usually heard on expiration Caused by narrowing of the airways
Rhonchi = low-pitched, continuous sounds Caused by secretions in the large airways Often clears with coughing
Lung Assessment (cont’d)Abnormal breath sounds (cont’d) --
Crackles = discontinuous sounds that may be high-pitched, popping sounds (fine crackles), or low-pitched, bubbling sounds (course crackles) Usually heard on inspiration
Stridor = piercing, high-pitched sound Primarily heard during inspiration Indicates respiratory distress
Stertor = labored breathing that produces a snoring sound
Retraction refers to the visible sinking of tissues around and between the ribs, sternum, or clavicles due to respiratory difficulty
Note clubbing, coughing, and signs of hypoxia
Cardiovascular AssessmentObserve the precordium (area of the chest
over the heart) for pulsations or heavesAbnormal anywhere except at the 5th ICS MCL
(‘point of maximal impulse’, or PMI)Associated with an enlarged ventricle
Palpate for ‘thrill’ (vibration or pulsation) over the chestMay indicate abnormal blood flow and/or
presence of a heart murmurAssess circulation
Palpate peripheral pulsesCheck capillary refillAssess Homan’s sign or calf tendernessAssess extremities for peripheral edema
Cardiovascular Assessment (cont’d)
Blood pressureCuff width should cover approximately 2/3 of the
length of the upper arm for an adult, and the entire upper arm for a child Incorrect cuff size can result in measurement error of
up to 30mmHg Using a cuff that is too large is better than using one
that is too smallUse the popliteal artery if brachial arteries
unavailable Systolic pressure may be 20-30mmHG higher in the
lower extremities, but diastolic pressure should be the same
Auscultate apical rate and rhythmListen to apical pulse for full minuteCompare apical pulse to radial pulses
Assessment of the ExtremitiesAssess for musculoskeletal abnormalities, as
major deformities may affect posture and gaitKyphosis = accentuated thoracic curveScoliosis = lateral ‘S’ deviation of the spineLordosis = accentuated lumbar curve
Assess balance and movement by having client tandem walking, heel-and-toe walking, deep knee bends, and hopping in place
Assess coordination via finger-thumb opposition and having client run the heel of one foot down the shin of the otherMovements should be smooth and controlled
Extremity Assessment (cont’d)Joints should be smooth, nontender, warm to
the touch, and of similar color to surrounding tissueColor changes may indicate inflammation or infectionAssess effect on joint function
Active ROM Passive ROM
Crepitus = clicking or grating at the joint
Assess muscle strength by applying resistance while client is performing active range of motion exercisesShould be strong and equal bilaterally
Test ‘hand grasp’ strength and ‘foot push’ strengthBoth should be equal bilaterally
Assessment of the Genitourinary System
The GI system consists of the external genitalia, rectum, urethra, bladder, kidneys, ureters, and prostate in malesCircumcision = excision of the foreskin of the
penis No longer recommended as routine practice Parental preference remains widespread
Hernia = protrusion of the intestine or other organ Typically found in the inguinal area in males May cause pain and distention
Hemmorrhoids = dilated, painful anal vessels Commonly seen in pregnancy, childbirth, constipation
Assess for problems or changes in voiding
Objective Two
Document findings by narrative charting
Narrative ChartingTells the story of the patient’s experience
in a chronological formatGoal = track client’s changing health
status and progress toward positive outcomes
Especially useful in constructing a timeline of events (i.e. cardiac arrest, etc)
Requires the writing out of the details of the patient’s care in sequence
Be sure to organize your thoughts prior to beginning your documentation, as it can be easy to ramble in narrative charting
Unit Two
Physical assessment techniques for the
lungs and abdomen
Objective One
Demonstrate the assessment
technique of light palpation and percussion to
abdomen
Examination of the AbdomenInspect and auscultate the abdomen first in
order to avoid stimulating/altering bowel sounds through percussion/palpation; bladder should be emptied prior to examination
Auscultate bowel sounds in all 4 quadrants of the abdomenDiscontinue NG suction (or clamp tube) if indicatedAbsent bowel sounds = no sound auscultated after
listening for 5 minutesHypoactive bowel sounds = very soft and
infrequent (i.e. 1 sound per minute)Hyperactive bowel sounds = loud, rushing sounds
occurring every 2-3 seconds
Examination of the Abdomen (cont’d)
Palpation of abdomenUse light palpation (pads of fingertips) to evaluate for
tenderness and guarding, superficial masses Involuntary rigidity of the abdominal muscles may indicate
peritoneal inflammationUse deep palpation to assess organs (this is an
advanced technique that is not usually performed by staff nurses) Liver border should be smooth and free of masses Should not be able to palpate the spleen
Abdominal percussion should be primarily tympanicLiver should be dull over right MCLStomach should be tympanic at left lower anterior
ribcageSpleen should be dull near left 10th rib posterior to MAL
Objective Two
Demonstrate the assessment technique of
percussion of the thorax and abdomen
Examination of the ThoraxThorax = formed by the ribs, sternum, and
vertebrae; protects the heart, lungs, and great vesselsAssess with client in sitting positionObserve sternal angle
Rib slope should be less than 90°Estimate chest diameter
Anteroposterior diameter should be twice the size of transverse diameter
‘Barrel chest’ (equal diameters) often seen with COPD Osteoporosis may shorten length of spine, pushing ribs
forward and downwardLight palpation of the lungs (perform both
anterior and posterior assessment)Assess symmetry of respiratory movement by
having client inhale deeply while grasping the lateral ribcage with thumbs level to the 10th ribs
Examination of the Thorax (cont’d)
Palpation of the lungs (cont’d) --Assess for tactile fremitus by having client repeat the
words ‘99’ while using palm of hand to palpate chest and back Identify areas of increased or decreased fremitus Fremitus is decreased (or absent) if the bronchus is
obstructed or there is fluid in the pleural space Fremitus is increased near large bronchi and over
consolidated lung tissue (i.e. pneumonia)Percussion of the lungs
Assess if underlying tissues are air-filled, fluid-filled, or solid
Identify level of diaphragmatic dullness bilaterally during respiration per posterior percussive assessment Have client fold arm across chest and percuss across the top
of each shoulder to identify lung apex Percuss symmetrical areas of lung while moving down
client’s back Percuss areas along the sides beneath the scapulae and
down the middle of client’s back
Examination of the Thorax (cont’d)
Percussion of the lungs (cont’d) --Systematically move down the chest wall for
anterior percussion assessmentShould percuss dullness over the heart (left of
the sternum from the 3rd to the 5th interspaces) Dullness replaces resonance when fluid or solid
tissue replaces airAbnormally high dull sounds indicate pleural
effusion or atelectasis Only a large amount of pleural effusion can be
detected per anterior percussion because fluid displaces posteriorly when client is in the supine position
Identify upper border of the liver by percussing dullness to the right of the thorax
Identify tympanic gastric air bubble via percussion to the left of the thorax
Unit Three
Physical assessment techniques for the eye, ear, and nose
Objective One
Demonstrate the proper use of the ophthalmoscope
Examination via Ophthalmoscope
Perform examination in a darkened roomSwitch on ophthalmoscope light; turn lens disc to 0Keep index finger on lens disc to facilitate refocusing
during assessment; use right hand when examining client’s right eye, and left hand when examining client’s left eyeUse large round beam (0) for large pupilsUse small round beam for small pupilsUse green/red beam to detect lesions
May use thumb of opposite hand on client’s eyebrow to guide movement, and to gently ‘lift’ upper lid if needed
Have the client look straight ahead at a specific point on the wall; hold scope firmly against your own face with your eye directly behind the sight hole
Hold scope 15 inches away, and about 15˚ lateral to client’s line of vision; shine beam of light on the pupil
Ophthalmoscopic Exam (cont’d)
Identify optic discShould be yellowish orange, oval or roundShould note branching of vessels away from the
optic disc, and progressive enlargement of vessel size as the vessels approach the disc
Disc outline should be clearLens should be transparent
Assess for the ‘red reflex’ (orange glow)Absence may indicate cataract, detached retina,
or artificial eyeKeep light beam focused on the red reflex as you
move ophthalmoscope closer to the pupilIdentify arterioles and veins
Arterioles are light red, smaller, with bright light reflex
Veins are dark red, larger, with absent light reflex
Ophthalmoscopic Exam (cont’d)
Adjust lens discUse clear glass lens for normal-sighted clientUse lens with longer focus and rotate lens disc
counterclockwise (minus diopters, or red numbers) for nearsighted client
Rotate lens disc clockwise (plus diopters, or black numbers) for farsighted client
Rotate progressively to +10 to +12 diopters to focus on the anterior structures of the eye
Observe macular area (which is responsible for central vision) by having client look directly into the beam
Identify retinal abnormalitiesFlame-shaped hemorrhages may indicate
hypertensionLarge, horizontal line may indicate preretinal
hemorrhageTiny red spots are indicative of diabetic retinopathy
Glaucoma
Cataract
Retinal Detachment
Conjunctivitis
Stye
Diabetic Retinopathy
Objective Two
Demonstrate the proper use of the
otoscope
Otoscopic ExaminationEar Assessment
Perform examination in a darkened roomUse the largest speculum the ear canal can
accommodateHave the client tilt head toward the side not being
examinedPull the helix up and back for adults, and down and
back for children under the age of 5 May be painful in clients with acute otitis externa
Insert speculum into outer 3rd of the ear canal; gently manipulate position to visualize the entire drum Observe for wax build-up, discharge, foreign body, redness
or edema Assess for ‘cone of light’ and bony landmarks (i.e. the
‘handle’ and a portion of the malleus)Nasal Assessment
Use short, wide nasal speculumObserve lower portions of the nose, then the upper
portions
Otoscopic Examination (cont’d)
Assessing the Nose (cont’d) --Use short, wide nasal speculumObserve lower portions of the nose, then the
upper portionsAssess the nasal mucosa
Should be slightly more red than oral mucosa Observe for edema, exudates, or bleeding
Inspect the nasal septum for bleeding or deviation (deviated septum is common in clients with chronic allergies, history of broken nose, etc)
Observe the inferior and middle turbinates and middle meatus for edema, exudates, and polyps; note color
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Objective Three
Assess the anatomical structures
visible with the ophthalmoscope/otos
cope
(*Lab Practice)
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