Chapter 28

Pulling It All Together:

Integrated Head-to-Toe
Assessment
Total Health Assessment
 Preparing the client
 Equipment
 Collection of data

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Integrated Assessments
 Musculoskeletal
 Neurologic

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Modifications to Physical Examination

 Observe spinal curvatures and check for scoliosis.

 Observe gait, including base of support, weight-bearing
stability, foot position, stride, arm swing, and posture.
 Observe the client as you ask the client to:
o Walk in a heel-to-toe fashion (tandem walk)
o Hop on one leg, then the other leg
o Perform finger-to-nose test
o Perform Romberg test

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Collecting Subjective Data
 Nursing health history
 General survey
 Mental status examination

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Collecting Objective Data #1
 Skin
 Head and face
 Eyes
 Ears

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Collecting Objective Data #2

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Question #1
Is the following statement true or false?
To test the functions of cranial nerve VII, the nurse should
ask the client to close his or her eyes and smell soap,
coffee, or vanilla.

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Answer to Question #1
False.
To test cranial nerve VII, the nurse should ask the client to
smile, frown, show teeth, blow out cheeks, raise eyebrows,
and tightly close the eyes. Cranial nerve I is assessed by
asking the client to close his or her eyes and smell soap,
coffee, or vanilla.

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Collecting Objective Data #3
 Nose and sinus
 Mouth and throat
 Neck
 Arms, hands, and fingers
 Posterior and lateral chest

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Collecting Objective Data #4

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Question #2

Which is done to assess graphesthesia in the client?

A. Write a number in the palm of client.
B. Ask the client to draw various shapes.
C. Ask the client about happenings of the past.
D. Ask the client about happenings today.

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Answer to Question #2
A. Write a number in the palm of client.
To assess graphesthesia, the nurse should write a number
in the client’s palm. Asking the client to draw shapes and
asking about happenings of the past and present are
included in the mental status examination.

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Collecting Objective Data #5

 Anterior chest
 Breasts
 Heart
 Abdomen

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Collecting Objective Data #6

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Collecting Objective Data #7

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Collecting Objective Data #8

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Collecting Objective Data #9
 Legs, feet, and toes
 Musculoskeletal systems
 Genitalia
 Neurologic systems

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Collecting Objective Data #10

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Data Analysis
 Nursing diagnoses
 Collaborative problems
 Referrals

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