Head to Toe Assessment

By Lucy McCarty, Chayton Watkins, and Genie Orlosky

Name: Abylin Watkins

Date of Birth: 04/29/2002
Gender: F
Age: 18
Weight: 135 lbs.
Height: 5’ 5”
BMI: Normal weight
Race: White
Religion: Non-denominational
Allergies: NKA

General Survey/Mental State: A.W. is an 18 y.o. female, alert and oriented x4. No obvious
deformities, appears well nourished, height and weight proportional, stated age seems
appropriate. Moves with smooth gait, seems comfortable and relaxed. Was able to identify
person, place, and time. Rates pain a 0 on a 0-10 numeric scale.

Skin/Nails: Skin is warm and dry, tan/pink color, with no present lesions or edema. Skin
turgor checked at the clavicle at <2 seconds elastic with no signs of dehydration. Nails and
well groomed and pink in color, with no signs of clubbing. Capillary refill was <2 seconds.

Head/Face: Normocephalic with no deformities, lesions, or masses with evenly distributed

hair. Face has no lesions, scarring, or masses and is symmetrical on both sides. Temporal
pulses are present 2+ bilaterally.

Eyes: Symmetric, moist, no crusting or drainage. Eyebrows/lashes are full and even.
Eyelids cover the top of iris with no redness or swelling. Conjunctiva is clear, sclera is
white, iris is round and regular with a brown color, cornea is clear with no cloudiness.
Pupils go from 5mm to 3mm. PERLA.

Ears: Symmetric bilaterally. No tenderness in the pinna, lobules or tragus. No clicks

present in the mastoid process. No redness, swelling, or cerumen in the auditory meatus.

Nose: Symmetric with no lesions or masses present. No drainage. Septum is midline. No

nasal obstructions.
Mouth: Lips are pink and moist and symmetric. Teeth, good oral hygiene, no decay. Gums,
mucosa, tongue, and sublingual area are pink and moist with no lesions. Hard and soft
palates are intact. Tonsils present 1+. Uvula rises midline with phonation.

Neck: Neck is symmetrical, trachea is midline, no signs of tenderness. Palpation of carotids:

strong, bilateral, 2+.

Lymph Nodes: Preauricular, postauricular, occipital, jugulodigastric, submandibular,

submental, anterior cervical, posterior cervical, deep cervical, and supraclavicular are all
0+, nonpalpable, and are not tender.

Thorax/Respiratory: AP transverse diameter is 2:1, no signs of masses, tenderness or

edema. Skin color is normal, no signs of deformities. Chest expansion is normal anteriorly
and posteriorly. No signs of adventitious sounds. Patient leaned forward: vesicular,
bronchovesicular, bronchial breath sounds were normal.

Cardiac: JVD test was performed with lamp overhead at 35 degrees: no signs of JVD.
Precordial area was inspected and shows no signs of lifts or heaves. Apical pulse was
inspected and palpated: pulse was palpable but not seen with overhead lighting. Aortic,
pulmonic, tricuspid and mitral valves were all assessed and auscultated. S1 is louder at the
apex, and S2 sounds were louder at the base. NO signs of extracardiac sounds or murmurs.
Rate and rhythm is normal.

Abdomen: Patient was supine: Inspection shows no signs of redness, swelling, edema and
shows signs of minimal stretch marks. Contour is rounded, no pulsations, and no
tenderness in 4 quadrants. Bowel sounds are present in all 4 quadrants and the percussion
test was normal. Stomach is soft and symmetric.

Peripheral Vascular: Extremities were compared bilaterally and are normal. No signs of
edema, redness, or swelling. Patient has a surgical scar on her left shoulder from acromion
surgery one year ago. Skin is proportionate for race, no varicosities present. Hair
distribution is normal. Temperature is warm, no signs of excessive moisture, no signs of
calf tenderness. No pitting edema 0+. Nail bed color is pink, no discoloration. Capillary
refill is less than two seconds.

Peripheral Pulses: Temporal, carotid, brachial, radial, popliteal, posterior tibial, and
dorsalis pedis pulses were all 2+, bilaterally.

Neuromuscular: (Patient was sitting.) Pupils are equal and reactive to light. From 5mm to
3mm. Ocular movements are within normal limits. Patient experienced no difficulty or
pain during upper or lower extremity ROM exercises. Displayed a full ROM bilaterally,
throughout the entire body. Strength in neck, shoulders, arms, hands, hips/spine, legs, and
feet is 5/5 bilaterally. The Romberg sign was negative/no sign of Rombergism. Patient had a
normal, coordinated gait. Experienced no loss of balance or shuffling. Tandem walk was
normal. Rapid alternating movements were normal. No signs of dysdiadochokinesia during
finger to nose or heel to shin testing. Spine appeared straight with no curvatures or
deviations. No sign of scoliosis, kyphosis, or lordosis present.

Nursing Diagnosis:
1. Diabetes: Ineffective health maintenance r/t demonstration of uncontrolled diabetes
and reporting lack of education of diabetes as evidenced by high blood sugar.
2. Hypertension: Patient has a risk for decreased cardiac output and imbalanced
nutrition.
3. Hypothyroidism: Activity intolerance r/t fatigue and depressed cognitive processes.

Patient Goals:
1. Pt. will be educated on the importance of controlling blood sugar, and report a
blood sugar of 120 mg/dL or less by the end of the day.
2. Pt. will be educated on the importance of maintaining a healthy diet combined with
exercise and rest, as these are coping mechanisms and interventions in which the
PT’s blood pressure will be decreased over time.
3. Pt. will be educated on the importance of medication compliance and follow-up
visits. Patient will understand that compliance to her med. regimen will be a lifelong
commitment and will schedule a follow-up visit for 30 days from now, at the
completion of our appointment.