PHYSICAL ASSESSMENT/
EXAMINATION
HEAD TO TOE
BY : NELSON MUTHALI DIP/RN
D A T E : 0 8 TH M A R C H , 2 0 1 3
OBJECTIVES
By the end of the topic students should be able to:1. Define physical assessment
2. Describe the four techniques used in physical
assessment
3. Know how to do a head to toe assessment
Physical assessment is a systematic data collection
method that uses the senses of sight, hearing, smell
and touch to detect health problems.
There are four techniques used in physical assessment
and these are: Inspection, palpation, percussion and
auscultation.
Usually history taking is completed before physical
examination.
Inspection
Inspection is the use of vision to distinguish the
normal from the abnormal findings.
Body parts are inspected to identify color, shape,
symmetry, movement, pulsation and texture.
Principals of inspection
 Availability of adequate light
 Position and expose body part to view all surfaces
 Inspect each area for size, shape, color, symmetry,
Position and abnormalities.
 If possible compare each area inspected with the
same area on the opposite side.
 Use additional light to inspect body cavities
Palpation
Palpation involves use of hands to touch body parts for
data collection.
The clinician uses fingertips and palms to determine
the size, shape, and configuration of underlying body
structure and pulsation of blood vessels.
It help to detect the outline of organs such as thyroid,
spleen or liver and mobility of masses.
It detects body temperature, moisture, turgor, texture,
tenderness, thickness, and distention.
Principles of palpation
 Help client to relax and be comfortable because
muscle tension impairs effective assessment.
 Advise client to take slow deep breaths during
palpation
 Palpate tender areas last and note nonverbal signs of
discomfort.
 Rub hands to warm them, have short fingernails and
use gentle touch
Percussion
Percussion is the technique in which one or both
hands are used to strike the body surface to produce
a sound called percussion note that travels through
body tissue.
The character of the sound determines the location,
size and density of underlying structure to verify
abnormalities.
An abnormal sound suggests a mass or substance like
air, fluid in an organ or cavity.
Auscultation
It involves listening to sounds and a stethoscope is
mostly used.
Various body systems like cardiovascular, respiratory
and gastrointestinal have characterized sounds.
Bowel, breath, heart and blood movement sounds are
heard using the stethoscope.
It is important to know the normal sound to
distinguish from abnormal.
Preparation for physical exam
Infection prevention
Follow standard/universal precaution through out
procedure.
Environment
P/A requires privacy and away from other distractions.
Equipment
Gather all the necessary equipment, equipment needs
to be warmed before being placed on the body e.g.
rubbing diaphragm of the stethoscope briskly
between hands.
Preparation cont…
Patient preparation
Prepare the patient physically and make the patient
comfortable throughout the physical assessment for
successful exam.
Explain to the patient everything to be done.
HEAD TO TOE ASSESSMENT
General survey
The assessment of the patient/client begins on the first
contact.
It includes apparent state of health , level of
consciousness, and signs of distress.
The general height, weight, and build can be noted
including skin color, dressing, grooming, personal
hygiene, facial expression, gait, odor, posture and
motor activity.
NOTE: If there is a sign of acute distress
comprehensive health assessment is deferred until
when patient is stable.
Vital signs
Assessment of vital signs is the first physical
assessment because positioning and moving the
client during examination interferes with obtaining
accurate results.
Specific vital signs can be also obtained during
assessment of individual body system.
Skin, Hair, scalp and Nails
Inspect all skin surfaces first or gradually while
assessing the systems.
Use the skills of inspection, palpation, and olfactory to
assess the function.
Skin
Inspect skin for color, edema, lesions, scars and
vascularity.
Palpate to notice moisture, temperature, and skin
turgor.
Hair and scalp
Assess and note type of hair i.e. long, coarse, thick,
brittle.
Note the color, distribution, quantity, thickness,
texture and lubrication.
On inspection separate the hair to determine the scalp.
Wear clean gloves if lesions and lice are probable.
Nails
The condition of the nails reflects the general health,
state of nutrition, occupation, and level of self care.
Nail biting can reveal the person’s psychological
state.
Inspect the nail bed for color, cleanliness, length,
texture, angle between nail and nail bed and folds
around the nail.
Palpate the nail for inflamation
Head and neck
The assessment of the head includes:- eyes, ears, nose,
mouth and pharynx.
The assessment of the neck includes:- lymph nodes,
carotid artery, thyroid gland and trachea.
Eyes
Assess visual acuity, position and alignment of the
eyes, eyebrows and eyelids.
Note any abnormal discharges and color of conjunctiva
and sclera.
Ears
It determines the intergrity of the ear structures and
hearing acuity. Inspect for sore and discharges
Nose and sinuses
Assess the integrity of the nose and sinuses by using
inspection and palpation.
Nose
Observe for shape, size, skin color, and presence of
deformity or inflammation.
Sinuses
The exam involves palpation. Incase of allergy or
infection the inside is inflamed and swollen so
palpate for tenderness
Mouth and pharynx
Assess mouth and pharynx to determine overall health
and hygiene.
Use pen light and tongue depressor to assess oral
cavity.
Lips
Inspect lips for color, texture, hydration, contour,
sores and lesions.
Buccal mucosa, gums, and teeth
Ask client to clench teeth and smile to observe to
observe teeth occlusion, symmetry. A symmetrical
smile shows normal nerve function.
Inspect teeth for hygiene, position, and alignment.
Let client open with lips relaxed, use tongue depressor
to inspect the mucosa for color, moisture and sores.
Inspect gums for color, edema, retraction, bleeding
and lesions.
Tongue and floor of mouth
Carefully inspect tongue on all sides as well as floor of
mouth for color, size, position, texture, moisture
sores and lesions.
Palate
Have client extend the head backwards, holding the
mouth open, inspect the hard and soft palate for
color, shape, texture and extra bonny prominences
or defects.
Pharynx
Let the client tip the head back slightly, open mouth
wide and say “Ah”, with penlight inspect the uvula
and soft palate, they should rise centrally as the
client say “Ah” to determine the function of cranial(
vagus ) nerve function.
Check the uvula and tonsils for redness and
inflammation.
Neck
Palpate the muscles, lymph nodes, carotid artery
jugular veins for tenderness and distention.
Thyroid gland
Ask client to hyperextend the neck and view the
thyroid and palpate for masses.
Normally thyroid gland is not visible.
Chest
Inspect the skin for scars, sores, color, lesions, chest,
movement and respiratory rate.
Palpate to notice any masses, and tenderness in axillae
and breast.
Lungs
Auscultate to assess respiratory and sounds from the
lungs and chest cavity.
Percussion is done to detect accumulation of fluid or
air in the chest cavity.
Heart
Auscultate to hear the heart sound.
Learn to know the normal heart sound to be able to
detect the abnormal
Breast
Inspect the breast for skin color, scars and lesions.
Palpate to notice any presence of masses.
Extremities
Upper and lower extremities
Inspect hand and legs for symmetry, alignment, skin
color, temperature, sores, scars, lesions
inflammation and varicosity.
Palpate for tenderness, edema and pulsation of
arteries. Use the brachial, radial, ulna, femoral,
popliteal, posterior tibia and dorsalis pedis pulses.
Check capillary refill on nails, clubbed toes /fingers
and joint mobility.
Deep tendon reflexes
Normally done on high risk patients and needs
specialized practice and special hammer to assess the
reflexes.
Areas that are assessed are on biceps, triceps, patella,
and Achilles.
Abdomen
Inspect the skin for color, sores, lesions, scars, position
of umbilicus, distention and contours.
Palpate for tenderness, masses and enlargement of
other organs like liver, spleen and kidney.
Ask for bowel and bladder elimination.
Percussion is used to detect the location of organs that
are normally palpable e.g. liver, spleen and
intestines.
Always auscultate before palpation or percussion
because touching can alter mobility of bowel and
increase sound.
Genitalia
Start assessment of genitalia with asking questions
and do inspection to confirm a positive answer.
Female
Ask about presence of abnormal discharge, sores,
warts and itching
Male
Ask any presence of sores, itching, warts and abnormal
discharge.
Rectum and anus
Inspect for the skin color, sores, hemorrhoids and
lesions.
Do digital palpation to examine the anal canal for
masses and sphincters function only when
important.
Reference
1. Ruth F. Craven Constance J. Hirnle, Fundamentals
of Nursing, Human Health and Function, sixth
edition(2009), Lippincott Williams & Wilkins.
2. Potter. Perry, Fundamentals of Nursing, 7th
edition(2009) Mosby Elsevier.
3. Barbara F. Weller, Nurses Dictionary for nurses
and health care workers, 24th edition,Elsevier.