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Comprehensive Head To Toe Assessment PDF
Comprehensive Head To Toe Assessment PDF
A full physical head to toe assessment is completed upon admission and at the start of
each shift. The focus is on vital assessment parameters, tracking changes from shift to
shift and should take no more than 5 minutes to complete. Several activities in the
assessment can be completed at the same time. Usually, it is individualized to fit the
clients condition, diagnosis and level of acuity.
Step 1:
Evaluate the clients level of consciousness, eye contact and responsiveness, color and
texture of the skin, any IVs, dressings or tubes visible. Ask appropriate questions to
determine orientation to time and place. Establish the nurse-client relationship at this
time.
Step 2:
Assess vital signs. While taking the clients pulse, feel the skin temperature and moisture.
Check bilateral radial pulses. Observe for edema in face or neck. Individualize the
assessment: for example, with a neurological condition, check pupils.
Step 3:
Remove clients gown or raise the gown. Use the stethoscope to listen to heart sounds,
apical pulse and breath sounds bilaterally. Observe breathing patterns, symmetry of chest
movement, shape of chest, and depth of respirations. Check for skin turgor.
Step 4:
Auscultate abdomen for bowel sounds. Use palpation and percussion techniques only if
appropriate to diagnosis. Palpate bladder if necessary (based on output). If catheter is in
place, observe urinary output for color, odor, consistency and amount.
Step 5:
Assess lower extremities for warmth, color, moisture, and presence of pedal and popliteal
pulses, muscle tone and sensation. Assess for pedal edema or general edema in the lower
extremities. Check traction or casted areas for skin breakdown, alignment and placement.
Step 6:
Have client turn onto side or sit at edge of bed. Assess posterior lung fields and symmetry
of chest movement with inspiration. Assess skin for pressure areas, particularly coccyx
and heels when client returns to side-lying position. Evaluate clients ability to move in
bed.
Abnormal
1 Drowsy
2 Difficult to awaken
3 Unable to give date, month,
place
4 Irritable
5 Memory deficit
6 Difficulty finding words
7 Does not recognize family
1 Eyes closed
2 Does not follow directions
0
Follow commands to
stick out tongue, squeeze
fingers, move extremities
1
Responds to painful
stimuli
0
Equality of Pupil: Equal
1
Reaction to Light: (using penlight in
darkened room, open eye being tested, cover
opposite eye): Pupil constricts promptly
2
Light Reflex: (both eyes open, shine
light in one eye only, observe opposite eye): both
pupils constrict
3
Accommodation: (ability of lens to
adjust to objects at varying distances): Lens can
adjust
I Olfactory
Sensory nerve
Recognizes odor in
each nostril separately
II Optic
Demonstrates visual
acuity
IV
Trochlear
V
Trigeminal
VI Abducens
Moves eye
laterally
VII Facial
Elevates eyebrows,
puffs cheeks,
recognizes tastes
VIII Acoustic
IX
Glossopharyngeal
Hears whispers
with each ear
separately
Mixed nerve: motor to parotid gland and Gag reflex at back
sensory to posterior taste buds
of tongue
X Vagus
Same as IX
XI Accessory
Shrugs shoulders
XII Hypoglossal
Subjective Questions:
11. Inquire about their eyes and visual abilities? Do they require any aids to see?
22. Inquire about their ears and earring abilities? Do they require any aids to hear?
Objective Assessment:
Normal
Eye Assessment:
1 Note visual acuity: observe ADLs
should perform adequately
Abnormal
1 Age related macular degeneration, near
and farsightedness
Ear Assessment:
1 Ask if they hear normal sounds as
you make them: should have no
difficulties
2 Note any external lesions: No
lesions should be noted
3 Discharge: should have no
discharge from ear
Nose Assessment:
1 Structural changes: able to breathe
regularly with mouth closed
2 Discharge: should only have
minimal discharge
Neck Assessment:
1 Note any lesions or swelling: can have occasional small,
mobile non-tender lymph nodes
1fungal infection
(Candidiasis)
1 Enlarged, tender,
immobile nodes
Chest Assessment:
Assessment of the chest includes lungs, breasts and heart. External aspects should be
observed including symmetrical movement, posture, shape of breasts and axilla area
along with internal components of lungs and heart.
The lungs extend from 2 to 4 cm above the third clavicle to the eighth rib at the midline.
Posteriorly the lungs extend from the third spinous process to the tenth process and on
deep inspiration to the twelfth process. Ensure when auscultating breath sounds to
alternate from left field to right field as you work your way down. Examination of the
chest usually proceeds from posterior to anterior with the client in the upright position.
Ask the client to breath a little deeper than usual through their mouth rather than nose
since this can produce extra sounds that mask true lung sounds.
The heart is located directly behind the sternum, with the left ventricle projecting into the
left chest. The action of the heart should be assessed both proximally and distally.
Proximal assessment involves evaluating heart sounds, heart rate, and rhythm to obtain
information about the mechanical activity of the heart. Distal assessment involves
evaluating the peripheral pulses to obtain information about the effectiveness of the
hearts pumping action. One method to assess heart sounds is to start at the aortic area,
move slowly across to the pulmonic area, down to the tricuspid area and over to the
mitral area. The most important thing to remember is to use a consistent method to
compare the different sounds.
Examples of heart and lung sounds can be heard at:
http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heartlung-sounds/
Breast assessment should include observing for lumps, drainage, dimpling of breast tissue
and asymmetry. Any changes that the client indicates should also be noted.
Subjective Questions:
11. Ask questions around breathing, exercise and tolerance.
22. Ask if they have any problems with their circulatory system.
33. Inquire about medications currently in use.
Objective Assessment:
Normal
Respiratory Assessment:
1 General shape:
straight spine, relaxed
breathing, level
shoulders, ribs that slant
downwards
2 Note respiratory Rate:
12-20 resp/min
3 Auscultation: No
extra sounds heard
symmetrical areas should
be the same in quality
and intensity
Heart Assessment:
Auscultation
1 Mitral Valve sound:
heard best over left, fifth
intercostal
Abnormal
1 Breathes sitting forward (emphysema), uses accessory
muscles (respiratory distress), curvature of spine, horizontal
ribs (COPD), bulging interspaces during exhalation
2 Increased rate may be due to fever, injury, surgery or
trauma to chest wall
3 Crackles (due to sudden opening of closed airways),
wheezes (air passing through narrowed airways), rhonchi
(low-pitched rumbling heard on inspiration/expiration-may be
cleared with coughing) Absent Breath soundsmay indicate
atelectasis, pneumothorax or pleural effusion Faint Breath
soundsmay indicate hypoventilation, early atelectasis and
COPD
1 Difficult
to palpate
2 Unequal
pulses
3 Weak
pulse
4 Absent
pulses
Objective Assessment: Abdominal assessment is best done while patient is lying flat in
bed. Inspection and palpation of genitalia can be done while assisting patient with
personal care or toileting.
Normal
Abdomen:
Inspection:
Client lying flat in bed
1 Contour of Abdomen: abdomen flat
from chest to pubis
2 Skin Appearance: no change in skin
color around umbilicus
3 Circumference: place tap around
largest circumference, draw two lines
(top/bottom): No increase in abdominal
circumference
Auscultation:
Bowel sounds: place stethoscope firmly
on right lower quadrant and count
sounds for 1 minuterotate to all
quadrants to assess
1 Bowel sounds gurgle about 5-30 per
minute
2 More sounds can be noted before and
after eating
Abnormal
1 Concave contour: due to inadequate
nutritional intake or inadequate food
absorption
2 Distended: caused by gas and fluid
accumulation due to decreased peristalsis,
hemorrhage or intestinal leakage post trauma
(surgery or auto accident)
3 Scars, stretch marks, dilated veins,
presence of hernia
4 Abdominal circumferences increasing
steadily within 1-2 hours may indicate
hemorrhage or ascites
5 Increased sounds: due to blood in GI tract,
diarrhea, or partial obstruction
6 Hypoactive sounds may be quiet and
infrequent due to
Urinary Tract:
1 Visually inspect the external urethra:
orifice is pink and moist, clear with
minimal discharge
2 Urine output: assess quantity, color,
odor, specific gravity and pH of urine.
Output should be 1200-1500ml/24 hours or
30-50 ml/hourshould equal oral and IV
intake
3 Clear, yellow-amber color
1 Slight odor
2 Specific Gravity: 1.003-1.030
3 Blood: check for blood using hemastix:
no blood should be present
4 Bladder Distention: Not normally
palpated
5 Pain: Assess for painshould be no
pain
Genital Assessment:
Male: Visually inspect the skin for lesions,
discharge and cleanliness
1 Clean, no odor, no discharge, no lesions
2 Noting groin area: no bulges in groin
3 Testicles: gently palpate each testicle
for size, shape and consistency: two
testicles in scrotum, no nodules, no
swelling or tenderness
Skin Assessment:
Initial skin assessment and grading is completed on all patients at the time of admission
using the Braden Scale for Predicting Pressure Sore Risk (PHC-EL029). Skin assessment
can be incorporated into other parts of the physical assessment, but it is important to
ensure that all areas of the body are checked. Pressure ulcers occur predominantly over
bony prominences, and excess moisture often causes breakdown in the buttock, inner
thigh, and groin areas. Patients with any of the following could be at risk for skin
breakdown: decreased sensory perception, increased moisture on the skin, decreased
activity, decreased mobility and
decreased nutritional intake. In addition the presence of friction or shearing on the skin, a
history of pressure ulcers and any disease process that impairs blood flow/perfusion also
increases patients risk for developing a pressure sore.
Subjective Questions:
11. Does this patient have a history of pressure ulcers, nutritional impairment,
diabetes or heart disease?
22. Is the patient mobile and active? Is there increased pressure or shearing that can
occur due to lack of mobility?
33. Is increased moisture noted on the skin (ie: incontinence, diaphoresis, weeping
edematous legs)?
Objective Assessment:
Normal
General Inspection:
1 Smooth, intact skin with
normal firmness or tensile
strength
2 Uniform warmth
3 Uniform color
Abnormal
1 Varicose veins (indicates circulation difficulties)
2 Abrasions, rashes, dermatitis, blisters, hematomas,
skin tears, lacerations, ulcers or wounds
3 Areas of hardness (indurations)
4 Areas of skin that are warmer or hot to the touch-can
indicate infection
5 Areas of the skin that are cooler than surrounding
areas (i.e. lower legs and feet can indicate circulation
difficulties)
6 Skin that is discolored can be sign of damage from
pressureappears reddened/bruised
1 Uniform hydration
clients ability to cope with the present situation, to assess the need and availability of
support systems and to determine the guidelines of the treatment plan.
Initial factors that the nurse must consider in completing a mental status assessment
include correctly identifying the client, the reason for admission, history of any previous
mental illness, present complaint, any personal history that is relevant (such as living
arrangements, history of alcoholism, domestic violence) and support systems available.
Subjective Questions:
11. What their admission is for and how long they are expected to be in hospital?
22. Any history of previous mental illness?
33. Any personal history that is relevant such as history of substance abuse or
domestic violence?
44. What support systems do they currently have available to them and do they have
pressing stressors that would worsen by staying in hospital (for example: financial
concerns or children to care for)?
Objective Assessment:
Normal
General Appearance, Manner and Attitude:
Physical Appearance: general characteristics, energy
level
Note grooming, mode of dress, and personal
hygiene: appropriate to grooming and dress to
situation, age and social circumstance, clean
Abnormal
1 Inappropriate appearance, high
or low extremes of energy
2 Poor grooming, inappropriate
or bizarre dress or combination of
clothes, unclean
1 Overactive, agitated or
impulsive
2 Repetitious activities
3 Disordered attention,
distracted, cloudy consciousness,
delirious, stuporous
Mood or Affect:
Assess variability in mood by observing
behavior and asking How are you feeling
right now?: appropriate, even mood
without high variations high to low
Assess depth and significance of mood if
questioning depression: may be sad or
grieving but mood does not persist
indefinitely
Memory:
Assess past and present memory and
retention: alert, accurate responses, past
and present memory appropriate
Assess recall with questions about birth
date, age or place of birth: good recall of
immediate and past events
Judgment:
Assess judgment and decision making
ability: ability to make accurate decisions,
realistic interpretations of events
Lifestyle Patterns:
Identify addictive patterns and effect on
individuals overall health: Normal amount
of alcohol ingested, smoking habits,
prescriptive medications, adequate food
intake
Coping Devices:
Identify defense-coping mechanisms and
their effect on the individual: conscious
coping mechanisms used
1reaction formation,
insulation or denial