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Head To Toe Assessment
Head To Toe Assessment
Head-To-Toe
Assessment
Group Members:
Binay, Rizalyn
Busa, Ana Marie
Cabiltes, Claitte
Diano, Christine
Nasayao, jannin
Ramos, Sunny
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Head-To-Toe Assessment
After 3 hours of classroom Discussion and Demonstration the
Level I students will be able to:
I. Define the FF. terms:
a. Nursing Assessment
b. Physical Assessment
c. Anthropometric Measurement
d. Health History
e. Health
f. Reflexes
g. Visual Activity
h. Interview
i. Signs
j. Symptoms
II.
a. Importance of Physical Assessment
b. Purpose of Physical Assessment
c. Four basic techniques in Physical Assessment
d. Principles involved in Physical Assessment
e. Nursing responsibilities before, during and after
Physical Assessment
f. Materials and Equipment used in Physical Assessment
III.
Demonstrate Beginning Skills in Physical Assessment.
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A. Nursing Assessment
- Is a major component of nursing care.
- Is a process which includes both physical and
psychological aspect to evaluate client’s condition.
- Enables the nurse to make a judgment about the
client’s health status , ability to manage his/her health
care and need for nursing.
B. Physical Assessment
- Is a process by which a nurse obtains a data that
describes a person’s responses to actual or potential
health problems shich is analyzed to form pertinent
diagnosis.
- Is a head to toe review of each body system that offers
objective information about the client and allows the
nurse to make clinical judgment.
C. Anthropometric Measurement
- Comparative measurements of the body.
Anthropometric measurements are used in nutritional
assessments. Those that are used to assess growth and
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II. Palpation
It is the act of touching a patient in a therapeutic
manner to elicit specific information. It follows and often confirms
points you noted during inspection. Palpation applies your sense
of touch to assess these factors: texture, temperature, moisture,
organ location and size, as well as any swelling, vibration or
pulsation, rigidity or spasticity, crepitation, presence of lumps or
masses and presence of tenderness or pain.
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IV. Auscultation
It is the act of active listening to the body organs to gather
information on patient’s clinical status. Auscultation includes
listening to sounds that are voluntarily and involuntarily
produced by the body such as the heart and blood vessels
and the lungs and abdomen. Auscultated sounds should be
analyzed in relation to their relative intensity, pitch, duration,
quality, and location.
Two types of auscultation: Indirect and direct auscultation:
1) Direct of Immediate auscultation
It is the process of listening with the unaided ear. This
can include listening to the patient from some distance
away or placing the ear directly on the patient’s skin
surface. And example is the wheezing that is audible to
the unassisted ear in a person having a severe
asthmatic attack.
2) Indirect or Mediate auscultation
It is the use of stethoscope, which transmits the sounds
to the nurse’s ear.
Before
• Always dress in clean professional manner, make sure you
have your name pin or workplace identification.
• Remove al bracelets, necklaces, or earrings that can
interfere during the physical assessment.
• Be sure your hair will not fall forward and obstruct your
vision or touch to the patient.
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During
After
• Provide recognition to the patient when the physical
assessment concluded; inform the patient what will happen
next.
• Place patient in a comfortable position.
• Do after care.
• Do medical hand washing.
• Document assessment findings in the appropriate section of
the patient record.
Dorsal recumbent
Back-lying position with knees flexed and hips externally
rotated; small pillow under the head; soles of feet on the surface.
Supine (horizontal recumbent)
Back-lying position with legs extended; with or without pillow
under the head
Sitting
A seated position. The back is unsupported and legs hanging
freely.
Lithotomy
Back-lying position with feet supported in stirrups; the hips
should be in line with the edge of the table.
Sims
Side-lying position with the lowermost leg flexed at the hip
and knee, upper arm flexed at the shoulder and elbow.
Prone
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Body Parts
Assessment of Body Parts Normal Findings
Head & Neck
Head
Inspection:
For size, shape & symmetry The head should be round
(normocephalic) and symmetrical.
Palpation:
For contour, masses, depressions. The normal skull is smooth, and
without masses or depressions,
non tender.
Hair
Inspection:
For color, evenness of growth over Can be black, brown or burgundy
the scalp, presence of parasites, depending on the race, evenly
amount of body hair. distributed covers the whole scalp
(no evidences of Alopecia), no
parasites, and the amount is
variable.
Palpation:
Thickness or thinness texture and Maybe thick or thin, coarse or
oiliness. smooth neither brittle nor dry.
Scalp
Inspection:
For Color, oiliness, presence of Lighter in color than the
scars, lice and dandruff. complexion, can be moist or oily,
no scars noted, free from lice, nits
and dandruff.
Palpation:
For lesions or masses tenderness. NO lesions should be noted,
neither tenderness nor masses.
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Forehead
Inspection:
For symmetry, skin appearance, Symmetrical, light to dark brown,
presence of rushes, scars or no rushes, scars and pimples.
pimples.
Palpation:
For masses, lumps and tenderness Non-tender, no lumps and
absence of masses.
Face
Inspection:
For shape and symmetry, The shape of the face can be oval,
presence of scars, pimples or acne round, or slightly square, the face
is symmetrical, absence of scars,
pimples or acne. There should be
no edema, disproportionate
structures, or involuntary
movements.
Palpation:
For any swelling, masses, lumps, No lumps and swelling of the face,
and the four sinuses (sphenoidal absence of masses and there is no
sinuses, frontal sinuses, ethmoid pain felt during palpation of face
sinuses and maxillary sinuses).
Eyes
Inspection: Symmetrical or evenly placed and
For symmetry. inline with each other. Non
protruding and equal palpebral
fissure.
Eyebrows
Inspection:
For hair distribution and alignment Hair evenly distributed; skin
and skin quality and movement, intact. Eyebrows symmetrically
presence of pimples, dandruff and aligned; equal movement,
color of the hair. absence of pimples and dandruff,
maybe black brown or blond
Palpation: depending on race.
For the presence of lumps, pain
and nodules. No lumps, no nodules and no pain
felt during palpation
Eyelashes
Inspection:
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Pupil
Inspection:
For color size, shape and equality
of the pupils Black in color; appears round,
regular, smooth border and of
equal size in both eyes, normally
3-7 mm in diameter.
Muscle function
Corneal Light Reflex or the
Hirschberg Test
(Observe the location of reflected
light on the cornea) The reflected light (light reflexes)
should be seen symmetrically in
the centers of the cornea.
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Cover Test
This test detects small degrees of
deviated alignment by If the eyes are in alignment, there
interrupting the fusion reflex that will be no movement of the either
normally keeps two eyes parallel. eye.
(Observe the cover eye for
movement)
Visual Acuity
Snellen eye Chart
The Snellen eye chart is the most
commonly used and accurate Normal Visual is 20/20
measure of visual acuity. The Top number (numerator)
indicates the distance the person
is standing from the chart, while
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Nose
External Inspection:
Inspect the nose nothing any The shape of the external nose
bleeding, inflammation, or lesions, can vary greatly among individual.
masses, swelling, and symmetry, Normally, it is located
discharges and color, sense of symmetrically on the midline of
smell. the face that is without swelling,
bleeding, lesions, or masses. No
discharge or flaring and uniform
color, there is a sense of smell.
External Palpation:
For tenderness and presence of
pain. Non-tender; absence of pain
Internal Inspection:
Inspect for nasal septum for
deviation, perforation, lesions and The nasal mucosa should be pink
bleeding. or dull red without swelling. The
septum is at the midline and
without perforation, lesions or
bleeding, the small amount of
watery discharge is normal.
Frontal Sinuses
Inspection:
For any swelling around the eyes
There is no evidence of swelling
Palpation: around the eyes.
Presence of pain and tenderness
The patient should not feel pain
during palpation and no
Percussion: tenderness felt.
Note any sound
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Transillumination of the
sinuses
You may use this technique in the The glow on each side is equal,
frontal and maxillary sinuses when indication air-filled frontal and
you suspect sinus inflammation, maxillary sinuses.
although it is of limited usefulness.
Mouth
Lips
Inspection:
For color, texture, cracking, The lips should be pink, soft moist,
symmetry, lesions and hydration smooth texture with no evidence
of lesions or inflammation. Not
crack and symmetrical.
Palpation:
For any presence of pain, lumps There is no presence of lumps and
and tenderness. pain. It is tender.
Gums
Inspection:
For color, texture, swelling, The gums should be pink, moist,
bleeding, retraction form the teeth firm texture, no retraction, no
swelling or bleeding. The gum
margins at the teeth are tight and
well-defined.
Palpation:
For the presence of pain, There should be no pain felt
tenderness and lumps. during palpation, no lumps and
non-tender.
Teeth
Inspection: The adult normally has 32 teeth,
For discoloration, numbers of which should be white, straight
tooth and texture. and smooth edges in proper
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Frenulum
Inspection:
For the color, texture. It should be attached to the
tongue, pinkish in color and moist.
Sublingual Area
Inspection:
For color, moisture and presence It should be pink in color, moist
of lesion. and no presence of lesions.
Hard palate
Inspection:
For color, shape, texture, The hard palate is concave and
presence of lesions and lighter in pink in color, it has many
malformation. ridges and it is moist, without any
lesion or malformation.
Soft Palate
Inspection: The soft palate is also concave
For color, shape, texture, and light pink in color, it is smooth
presence of lesions, malformation and no lesions or malformations
noted.
Uvula
Inspection:
For position, mobility and color. It normally looks like a flesh
pendant hanging in the midline of
soft palate. Tonsils are present
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Ears
External ear
Inspection:
For position, color, size, shape, The ear matches the flesh color of
any deformities, inflammation, or the rest of the patient’s skin and
lesions should be positioned centrally and
in proportion to the head. The top
of the ear should cross an
imaginary line drawn from the
outer canthus of the eye to the
occiput with no swelling or
thickening. Cerumen should be
moist and not obscure the
lympanic membrane. There should
be no foreign bodies, redness,
drainage, deformities, nodules or
lesions.
Palpation:
Presence of pain, tenderness, and They should feel firm (not tender)
lumps. and movement produce pain.
Auditory Acuity
Voice-Whisper test The patient should be able to
repeat words whispered from a
distance of 2 feet.
Neck
Inspection:
For symmetry of the The muscles of the neck are
sternocleidomastoid muscles symmetrical with the head at a
anteriorly, and the trapezius central position. The patient is
posteriorly. able to move head through a full
range of motion without complaint
of discomfort or noticeable
limitation. The patient may be
breathing through a stoma or
tracheostomy.
Palpation:
For the presence of masses and
tenderness. The muscles are symmetrical
without palpable masses or
spasm.
Lymph Nodes
Inspection:
For any enlargement or
inflammation.
Lymph nodes should not be visible
Palpation: or inflamed.
For size, shape, dellimination,
mobility, consistency, and
tenderness Normally, lymph nodes should not
be palpable in the healthy adult
patient; however, small, discrete,
movable nodes are sometimes
present but are of no significance.
Trachea
Palpation:
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For clients who have respiratory The skin should be intact; uniform
complaints. temperature.
For respiratory excursion
Palpation:
Perform palpation to judge the
size, location and consistency of
certain organs and to screen for
an abnormal mass or tenderness.
Hooking Technique
An alternative method of
palpating the liver. Stand up at
the persons’ shoulder and swivel
your body to the right so that you Normally you should feel nothing
face the person’s feet. Hook your firm. When enlarged the spleen
fingers over the costal margin extends into the lower quadrants.
from above. Ask the person to
take a deep breath then try to fell
the liver edge bump from your
fingertips.
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Spleen Palpation:
Search spleen by reaching your
left hand over the abdomen and
behind the left side at the 11th A person normally feels a thud but
and 12th ribs. Lift for support. no pain.
Place your hand obliquely on the Sharp pain occurs with
LUQ with the fingers pointing inflammation of kidneys or
toward the left axilla and just paranephric area.
inferior to the rib margin. Push
your hand deeply down and under
the left costal margin and ask the
person to take a deep breath.
Kidney
Percussion:
Indirect fist percussion causes the
tissues to vibrate instead of
producing a sound. Locate kidney Lower pole of the kidney is round,
by placing hand over the 12th rib smooth mass slide in between
at the costoverbral angle on the your fingers.
back. Thump that hand with the
ulnar edge of your other fist.
Palpation:
locate kidney by placing your
hand together in a duck-bill
position at the person;s right
flank. Press your two hands
together firmly (you need deeper
palpation than that used to liver
and spleen) then ask the person to
take a deep breath.
Palpation:
Light palpation in all 4 quadrants
Deep palpation in all 4 quadrants
Extremities
Upper and Lower
Inspection:
-Observe for size, color, contour,
symmetry and involuntary Both extremities are equal in size
movement
Balance Test
Gait
Observe as the person walk 10-20 feet, turns and
returns to the starting point. Normally, the person moves with a
sense of freedom. The gait is smooth, rhythmic, and effortless,
the opposing arm swing is coordinated, and the turns are smooth.
Romberg’s Test
Ask the person to stand up with feet together and arms
at the side. Once in a stable position, ask the person to close the
eyes and to hold the position. Wait about 20 seconds. Normally, a
person can maintain posture and balance even with the visual
orienting information blocked, although slight swaying may occur.
(Stand close to catch the person in case he or she falls)
Tandem Walking
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Upper Extremity
Biceps Reflex (Flexion)
Support the person’s forearm on yours; this position relaxes, as
well as partially flexes, the person’s arm. Place your thumb on the
biceps tendon and strike a blow on your thumb. You can feel as
well as see the normal response, which are contraction of the
biceps muscle and the flexion of the forearm.
Triceps Reflex (Extension)
Tell the person to let the arm “just go dead” as you suspend it by
holding the upper arm. Strike the triceps tendon directly just
above the elbow. The normal response is extension of the
forearm.
Brachioradialis Reflex (Flexion and Supination of the arm)
Hold the person’s thumbs to suspend the forearm in relaxation.
Strike the forearm directly, about 2 to 3 cm above the radial
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Lower Extremity
Quadriceps Reflex (patellar or knee jerk reflex)
Let the lower legs dangle freely to flex the knee and stretch the
tendons. Strike the tendon directly just below the patella.
Extension of the lower legs is the expected response.
Achilles Reflex
Position the person with the knee flexed and the hip externally
rotated. Hold the foot in dorsiflexion, and strike the Achilles
tendon directly. Feel the normal response as the foot plantar
flexes against your hand.
Plantar Reflex
Position the thigh in slight external rotation. With the reflex
hammer, draw a light stroke up the lateral side of the sole of the
foot and inward across the ball of the foot, like an upside-down J.
The normal response is plantar flexion if all the toes and inversion
and flexion of the forefoot.
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Appendices
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Tuning Fork
Cotton Applicators
Nasal Speculum
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Prone
Indirect Percussion
Direct Percussion
Side View
Sinus’ Locations
Front View
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Posterior Anterior
Respiration Patterns
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Adventitious Sounds
Sound Site Cause Character
Auscultated
Crackles Are most Random, Fine crackles are high-
commonly sudden pitched fine short
heard in reinflation of interrupted crackling
dependent groups of sounds heard during end of
lobes; right alveoli; inspiration, usually not
and left disruptive cleared with coughing.
lung bases. passage of Moist crackles are lover,
air more moist sounds heard
during the middle of
inspiration; not cleared with
coughing. Coarse crackles
are loud, bubbly sounds
heard during inspiration not
cleared with coughing
Ronchi Are Muscular Are loud low – pitched,
(sonorous wheeze) primarily spasm, fluid rumbling coarse sounds
heard over or mucus in heard most often during
trachea and larger inspiration and expiration;
bronchi; if airways, may be cleared by
loud cause coughing.
enough, turbulence.
can be
heard over
most lung
fields
Wheezes Can be High – Are high-pitched continuous
(sibilant wheeze) heard all velocity musical sounds like a
over lung airflow squeak heard continuously
fields through during inspiration, or
severely expiration; usually louder
narrowed on expiration
bronchus
Abdominal Quadrants
Abdominal Viscera and Vascular
Structures
Vascular sounds and friction rubs can best be heard over these areas
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Kidney Palpation
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Heel-to-sheen test
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Triceps Reflex
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Plantar Reflex
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Sites for Auscultating the Abdomen Percussion Sites for all Quadtrants
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Diaphragmatic Excursion
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