Head-to-Toe Assessment General Appearance: Patient appears conscious and coherent alert and oriented to time, place and

person lethargic and weak in appearance needs assistance to move and ambulate pale in appearance Area Assessed Normal Findings Actual Findings Analysis 1. Skull A. Inspects skull for &ounded &ounded 'normocephalic( Normal 1. si e 'normocephalic( symmetrical with $rontal, !. shape symmetrical with parietal, and occipital ". symmetry $rontal, parietal, prominences: smooth skull and occipital contour) #. Palpates $or prominences: tenderness o$ smooth skull mass%nodules, contour) depressions and No mass%nodules, tenderness depressions and tenderness Normal No mass%nodules, depressions and tenderness 2. Hair and Scalp A. Inspects for 1. *olor o$ +calp !. ,dor ". Presence o$ dandru$$ in$ection -. .esions B. Inspects for 1. *olor o$ /air !. 0istribution ". 1hickness% 1hinness -. 1e2ture 3. ,iliness 4. Presence o$ lice, nits, split ends 5. .ength 3. Face A. Inspects for 1. *olor o$ 8

6venly distributed +ilky, resilient hair '7) in$ection '7) in$estations

1he hair are une9ually distributed with thin hair strands: well kept:

Normal

Normal No lice or dandru$$ seen or noted.

+ymmetric% +lightly

+lightly pale in color

Abnormal 0ue to low hemoglobin

+kin !. +ymmetry ". 1e2ture -. +hape%*ontour

asymmetric $acial $eatures Palpebral $issures e9ual in si e +ymmetric nasolabial $old

+ymmetric% +lightly asymmetric $acial $eatures Palpebral $issures e9ual in si e +ymmetric nasolabial $old ';) rooting re$le2 when stroked near the cheek

count Normal

Normal

Normal . 4. Eyes A. Inspects the eyebrows for 1. color !. hair distribution and alignment /air evenly distributed +kin intact 6yebrows symmetrically aligned 8 1he eyelashes are e9ually distributed and slightly curled outward. with no discharge or discoloration on the eyelids. Normal

1he eyelashes are e9ually distributed and slightly curled outward.

Normal

B. Inspects the eyelashes for 1. 0istribution !. 0irection o$ curl C. Inspects the eyelids for 1. +ur$ace *haracteristics !. Position in relation to corner ". .ower lids when eyes closed -. Ability to blink and $re9uency

+kin intact '7) discharge , no visible sclera above corneas, and upper and lower borders o$ cornea slightly covered

+kin intact '7) discharge , no visible sclera above corneas, and upper and lower borders o$ cornea slightly covered

1here is blinking re$le2 when sudden light appears and when touch

Normal

.ids close symmetrically 137!< involuntary blinks%min #ilateral blinking =hen lids open

Pale con>unctiva Abnormal 0ue to low hemoglobin count D. Inspects conjunctiva for 1. color !. te2ture ". lesions -. $oreign bodies #ulbar con>unctiva is transparent: capillaries sometimes evident +clera appears white ?ellowish in dark7 skinned, Palpebral con>unctiva is shiny, smooth and pink or red. 1he pupils are black round and e9ual in si e and are reactive to light accommodation Normal

1he cornea is transparent, shiny, and smooth.

Normal

E. Inspects the cornea for 1. clarity !. te2ture ". transparency -. depth F. Palpates lacri al !land and nasolacri al duct for 1. edema !. evidence o$ tearing ". Inspects the pupils for 1. color !. shape ". symmetry o$ si e -. direct and consensual reaction to light

1he lacrimal gland and nasolacrimal duct o$ the client when palpated were not tender. 1here is also no evidence o$ tearing. 1ransparent, shiny, and smooth 0etails o$ the iris are visible Normal 1he pupils o$ my client are black in color, e9ual in si e, and round.

No edema or tenderness over lacrimal gland No edema or tearing Pupils constrict when looking near ob>ect Pupils dilate when looking at $ar ob>ect #lack 69ual in si e Normally "75 mm &ound +mooth #order @ris $lat and round @lluminated pupil

Normal

Normal

Normal

constricts Non illuminated pupil constricts Pupils constrict when looking near ob>ect Pupils dilate when looking at $ar ob>ect 'Pupils 69ually &ound and &eactive to .ight and AccommodationAP 6&&.A) 5. Ears A. Inspects auricles for 1. color !. symmetry o$ si e ". position B. Palpates for 1. te2ture !. elasticity ". areas o$ tenderness C. Inspects e#ternal ear canal for 1. cerumen !. skin lesions, pus, blood

*olor same as $acial skin +ymmetrical Auricle aligned with outer canthus o$ eye, about 1< degrees $rom vertical Bobile, $irm, and not tender Pinna recoils a$ter it is $olded 0ry cerumen, grayish7tan color: or sticky, wet cerumen in various shades o$ brown No skin lesions, pus or blood +ymmetric and straight No discharge or $laring Cni$orm color

1he ears are symmetrically aligned and the color is same as the $acial skin, @t is $irm and not tender. Normal

No serum and discharges noted. No skin lesions, pus or blood

6. ose and Sinuses A. Inspects e#ternal nose for 1. shape !. si e ". color -. $laring 3. discharges

1he nose is symmetrically aligned with the $ace, no discharges. @t is the same color with the $ace. Normal @t is not tender and no

B. Palpates for 1. areas o$ tenderness, masses C. Deter ine patency of nasal cavities D. Inspects for linin! of the 1. nares !. nasal septum ". redness% swelling E. Palpates a#illary and frontal sinuses for 1. tenderness

lesions present. Normal No tenderness: no lesions Air moves $reely as the client breathes through the nares Nasal septum intact and in the middle Bucosa pink *lear, watery discharge No lesions Not tender Nasal septum intact and in the middle Normal 1he mucosa is pink. Normal 1he sinuses are not tender when palpated.

!. "out# and $rop#aryn% A. Inspects and palpates lips and buccal ucosa for 1. color !. moisture ". te2ture -. presence o$ lesion B. Inspects the !u s for 1. condition !. color ". te2ture o$ gums C. Inspects the ton!ue for 1. sur$ace !. position ". te2ture -. movement

Cni$orm pink color Pale Bucous Bembranes +o$t, moist, smooth te2ture +ymmetric o$ contour . No ulcerations or lesions noted. 1he tongue moves $reely and not tender. 1he client possesses pink gums with a number o$ teeth only.

Abnormal 0ue to inade9uate hemologlobin count

Normal

Pink gums Boist, $irm gum te2ture '7) retraction o$ gums

*lient has complete set o$ yellowish teeth 1he gums are slightly pink, dry, has a $irm te2ture and no retraction o$ gums.

Normal Abnormal @ndicates dehydration or thirst

1he tongue o$ the client is

in central position, pink in color, no lesions and can move $reely. D. Inspects the outh floor and roof for 1. color !. te2ture E. Palpates ton!ue for nodules$ lu ps or e#coriated areas. F. Inspects hard and soft palate for 1. color !. shape ". te2ture 1here are evidence o$ prominent veins on the smooth mouth $loor . 1here are no palpable nodules but the tongue is smooth.

Normal

*entral position Pink color +mooth lateral margins '7) lesions Boves $reely +mooth tongue base with prominent veins

Normal

Normal 1he smooth palate is light pink and the hard palate is lighter than the smooth. 1he uvula o$ the client is in the midline o$ the so$t palate.

+mooth with no palpable nodules .ight pink, smooth palate .ighter pink hard palate, more irregular in te2ture Cvula in midline o$ so$t palate

Area Assessed

ormal Findin&s

Actual Findin&s

Analysis

'. eck Inspect the neck uscles for a. +welling or masses b. /ead movement Buscles e9ual in si e: head centered. *lientEs head is centered. Normal

*oordinate, *oordinate, smooth smooth movements movements with no with no discom$ort. discom$ort. /ead $le2es -3D /ead hypere2tend 4<D /ead laterally $le2es -3D /ead laterally rotates 5<D

Palpates the ly ph nodes for enlar!e ent. Palpates trachea for any lateral deviations. Palpates the thyroid !land for a. +moothness b. Areas o$ enlargement, masses or nodules. (. )osterior T#ora% Inspect posterior thora# to for a. +hape b. +ymmetry Inspect the spinal ali!n ent for defor ities

Not palpable *entral placement in midline: spaces are e9ual in both sides. .obes may not be palpated. @$ palpated, lobes are small, smooth, centrally located, and painless and rise $reely with swallowing. Anteroposterior to transverse diameter is 1:! ratio *hest symmetric +pine vertically aligned.

1here are no palpable nodes on client neck. @t is in the center o$ the neck and the spaces are e9ual in both sides. .obes are not palpable.

Normal Normal

Normal

*lient has ratio o$ 1:! in anteroposterior to transverse diameter: she has also a pigeon type o$ chest symmetric. +pine is vertically aligned with evident curves in cervical and

Normal

Normal

a. *ervical b. 1horacic c. .umbar Palpates the posterior thora# for a. 1emperature and integrity b. Areas o$ tenderness, bulges, abnormal movements c. *hest e2cursion d. Focal 'tactile) $remitus Percuss the thora# and identifies percussion notes a. &esonant b. Flat c. 0ull d. 1ympanic Auscultate the chest for breath sounds.

+pinal column straight, & and . shoulders and hips at the same height Cni$orm temperature +kin intact *hest wall intact No lumps, masses areas o$ tenderness

lumbar spine. . and & shoulders are in the same height. *lientEs temperature is uni$orm. +kin is intact same as chest wall. By thumb moves or separate about "73 cm. when she inhales. 1here are no lumps, masses areas o$ tenderness Normal

&esonance e2cept over scapula 0ullness over ribs Flat over bone or muscle 1ympanic over stomach. Fesicular, #roncho7vesicular, #ronchial

&esonance e2cept over scapula 0ullness over ribs Flat over bone or muscle 1ympanic over stomach.

Normal

Normal No adventitious sounds

1*. Anterior T#ora% Inspect the anterior thora# for a. #reathing patterns b. *oastal angle and the angle at which ribs enter the spine Palpates the

Guiet rhythmic and Normal && e$$ortless respiration. *ostal angle is H I<D. &ibs insert into spine at -3D angle.

Normal

Cni$orm

Cni$orm temperature.

Normal

anterior chest for a. 1emperature, integrity o$ skin b. Areas o$ tenderness, bulges, abnormal movements c. *hest e2cursion d. 1actile 'vocal ) $remitus 'male only) Percuss the anterior chest a. &esonant b. Flat c. 0ull d. 1ympanic

temperature. +kin intact. *hest wall intact. No lumps, masses areas o$ tenderness. #ilateral symmetry o$ vocal $remitus.

+kin intact. *hest wall intact. No lumps, masses areas o$ tenderness. #ilateral symmetry o$ vocal $remitus. ';) retractions Normal

Auscultate the a. 1rachea b. #reath sounds

&esonance down to 4th rib J diaphragm level Flat over heavy muscles and bone 0ull over the heart and the liver 1ympanic over underlying stomach #ronchial breath sounds #ronchovesicular and vesicular breath sounds

&esonance down to 4th rib J diaphragm level Flat over heavy muscles and bone 0ull over the heart and the liver 1ympanic over underlying stomach

Normal

Normal No adventitious sounds

11. Heart+ ,arotid Arteries+ -u&ular .eins

Inspect and Palpates the followin! areas a. Aortic b. Pulmonic c. 1ricuspid d. Apical e. 6pigastric $or pulsation

No pulsation

No pulsation

Normal

No pulsation No li$ts or heaves Pulsation visible in 3<K adults Palpable in most PB@ in 3th .@*+ B*. No li$ts or heaves Aortic pulsations

No pulsation No li$ts or heaves Pulsation visible in 3<K adults Palpable in most PB@ in 3th .@*+ B*. No li$ts or heaves Aortic pulsations

Auscultates the heart in all four sites% Aortic, Pulmonic, 1ricuspid, Apical 'Bitral) Palpates the carotid artery

+17 all sites, esp at apical +!7 all sites, esp base o$ the heart +"7 in children% young adults +-7 older adults +ymmetric pulse volume Full pulsation, thrusting 9uality Guality remains the same when ct breathes, turn head, changes sitting to supine 6lastic arterial wall

+17 all sites, esp at apical +!7 all sites, esp base o$ the heart +"7 in children% young adults +-7 older adults +ymmetric pulse volume Full pulsation, thrusting 9uality Guality remains the same when ct breathes, turn head, changes sitting to supine 6lastic arterial wall

Normal

Normal

Inspect the ju!ular vein for distention

Fein is not visible

Fein is not visible

Normal

12. /reast and A%illae Inspect breasts for a. +i e b. +hape%conto ur c. Any discoloration %hyperpigme ntation d. +welling or edema Palpates breasts for a. Basses, tenderness b. 0ischarge o$ nipples Inspect the areola a. +i e b. +hape%conto ur c. +ymmetry d. *olor e. +ur$ace characteristic s Palpates the areola and nipple for a. 1enderness, masses b. Presence o$ any discharge

Normal +kin uni$orm in color +kin smooth and intact No swelling No discoloration%hyper pigmentation. No swelling or edema No tenderness and discharge +kin uni$orm in color +kin smooth and intact 6ven with chest wall 1here is no presence o$ edema or swelling

No tenderness and discharge

Normal

&ounded or oval ,val bilaterally the bilaterally the same same *olor varies *olor is pink brown widely, $rom light to pink brown.

Normal

No tenderness, masses, nipple discharge and nodules

No tenderness, masses, nipple discharge and nodules

Normal

13. A0domen Inspect the abdo en for a. +kin integrity b. *ontour%sha pe c. +ymmetry d. Abdominal movement in relation o$ respiration

Cnblemished skin, uni$orm color 'no lesion) +ilver7white striae 'stretch marks) or surgical scars Flat, &ounded 'conve2) or +caphoid 'concave) +ymmetric contour No evidence o$ spleen or liver enlargement

1he abdomen distended

is

Abnormal 0istended abdomen Bay indicate in$lammation%swelling or parasitic in$ections

Auscultates abdo en for a. #owel sounds b. Fascular sounds c. Friction rubs

Audible bowel sounds 'heard every 3 to !< seconds) "7!< #owel sounds% minute Absence o$ arterial bruits Absence o$ $riction rubs. 1ympany over the stomach and gas7 $illed bowels: 0ullness over the liver and spleen, or a $ull bladder B*.: 471! cm '!.37".3 inches) Bidsternal: -7L cm. '1.37" in.) No tenderness, rela2ed abdomen with smooth, consistent tension

/yper active bowel sounds

Abnormal @ndicates increased bowel activity

Percusses the abdo en in each of the four &uadrants $or tympany and dullness Percusses the liver to deter ine si'e Perfor s li!ht palpation of the abdo en to detect areas of tenderness and

Absence $or tympany and dullness

Normal

B*.: Lcm Bidsternal:- cm. &educed skin turgor 1second

Normal

Abnormal &educed skin turger due to diarrhea

uscle !uardin! Perfor deep palpation over all four &uadrants Palpates liver to detect enlar!e ent and tenderness Palpates the bladder for distension 14. 1pper E%tremities Inspect the shoulder$ elbow$ wrist$ hand and fin!ers for a. #ony structure b. #ony prominences c. Buscle mass d. Moint structure e. +ymmetry

No tenderness, rela2ed abdomen with smooth, consistent tension Bay not be palpable #orders $eel smooth Not palpable

1enderness in the lower 9uadrants Not palpable. 1here is no enlargement o$ liver Not palpable

Abnormal Pain or discom$ort due to swelling or in$lammation in the abdomen

Normal

69ual si e on both sides No swelling% tenderness No nodules or crepitation

69ual si e on both sides No swelling% tenderness No nodules or crepitation

Normal

(bserves the shoulder$ elbow$ wrist$ hand and fin!ers for ran!e of otion a. Fle2ion b. 62tension c. Abduction d. Adduction e. &otation 'internal, e2ternal) Palpates the elbow$ wrist$ hand and fin!ers for

Bobile, $irm, no tenderness

As observed, the client is able to e2ecute the re$le2es.

Normal

Normal 1emperature is uni$orm 1emperature is uni$orm

a. #ony landmarks b. Buscle si e c. Moint structure d. 1emperature 15. 2o3er E%tremities Inspect the hip$ knee$ ankle$ foot and toes for a. #one structures and #ony landmarks b. Buscle mass c. Moint structure

No swelling% tenderness No swelling% tenderness

69ual si e on both sides No swelling% tenderness No nodules or crepitation

69ual si e on both sides No swelling% tenderness No nodules or crepitation

Normal

(bserves the $ knee$ ankle$ foot and toes for a. Fle2ion b. 62tension Palpates the hip for a. #ony landmarks b. Moint structure c. 1emperature

Bobile, $irm, no tenderness

1he client is able to e2ecute the $le2ion, e2tension o$ $oot and toes

Normal

Normal 1emperature is uni$orm No swelling% tenderness 1emperature is uni$orm No swelling% tenderness