lOMoARcPSD|16245032 Headto Toe Assessment Guideby Scrub Studies Nursing (Cincinnati State Technical and Community College) Scan to open on Studocu Studocu is not sponsored or endorsed by any college or university Downloaded by Salv Fuent (salv.chamizo@gmail.com) lOMoARcPSD|16245032 Head-to-Toe Assessment Overview The Sequence Goal is to differentiate between normal and abnormal. Look for unusual asymmetry Pay attention to non-verbal cues: Grimacing / grunting Avoiding eye contact Reluctance to answer questions Use open-ended questions to gather unbiased info Inspect - Look/smell Palpate - Feel The Sequence For Abdomen Inspect - Look/smell Auscultate - Listen Percuss - Tap Auscultate - Listen Palpate - Feel Percuss - Tap Introduction Ensure patient privacy Make sure room at comfortable temperature Knock- Introduce yourself Wash hands Sit/stand at eye level and make good eye contact Verify patient ID and DOB Explain why you are there Explain everything you do throughout the exam Always ask before touching Vitals/Mental Status Note: General appearance Behavior Mood Speech Hygiene Nourishment level Posture and Mobility Level of consciousness Ask: What is your name? What brings you here today? Who is the current U. S. president? A+O x4= Oriented to Person, Place, Time and Situation Take Vitals: Pulse Blood pressure Oxygen Saturation Temperature Respirations Skin Skin is an excellent measure of overall wellness! Assess skin throughout the exam Note if: Unusually pale Flushed Cold/hot Clammy Dry Downloaded by Salv Fuent (salv.chamizo@gmail.com) Also note: Lesions Abrasions Rashes Skin Turgor Tenderness Lumps lOMoARcPSD|16245032 Head, Face and Hair Hair (Scalp): Hair evenly distributed No signs of infection, infestation or skin breakdown Check for tenderness Head and Face Round Symmetrical No nodules or masses Test CN VII and CN V Palpate temporal artery and temporomandibular joint Eyes Look for any discoloration or abnormalities in: Eyelids Cornea (transparent) Sclera (white) Iris Conjunctiva (transparent) Pupils should be black and equal in size Check PERRLA Assess coordination by asking pt to move eyes in 6 cardinal positions Test vision with SNELLEN chart pupil iris Ears Inspect and palpate auricles for lesions and tenderness Assess ear discharge and tympanic membrane Check for symmetry between eyes and ears Check auricle recoils when folded Check Whisper and Tuning Fork tests Palpate the mastoid process for swelling or tenderness auricle (pinna) Nose Inspect for symmetry and discharge Check septum and insides nostrils- mucous membranes should be intact and pink Turbinates should not be swollen Palpate nose and sinuses for tenderness Verify patency of nares (nostrils) Check patient sense of smell Throat and Mouth Inspect: Lips- pink, moist and symmetrical. Able to whistle Breath- no strong odor Teeth- clean, white, smooth with pink gums Buccal mucosa- pink, moist, soft Tongue- pink, moist, centrally located. No white coating. Test CN XII Uvula- midline. Test CN IX and CN X Downloaded by Salv Fuent (salv.chamizo@gmail.com) Inspect: Tonsils- no inflammation Smooth palates- light pink and smooth Hard palates- more irregular texture Palpate jaw joint lOMoARcPSD|16245032 Neck and Shoulders Neck muscles equal in size Smooth head movement with no discomfort Inspect and palpate trachea- in midline with no masses Check shoulder shrug w/resistance Check for Jugular Venous Distortion Palpate lymph nodes from lower head and down the neck Palpate thyroid while pt swallows and assess for enlargement or masses Palpate carotid pulse Lungs, Thorax and Spine Spine vertically aligned Right and left shoulders are of the same height Chest round/convex and symmetrical Ask if experiencing any coughing or respiratory problems Assess respiratory expansion Listen to lung sounds front and back Heart Auscultate heart sounds: Rmbr: APE To M an A ortic- 2nd right intercostal space P ulmonic- 2nd left intercostal space E rb's- 3rd left intercostal space T ricuspid- 4th left intercostal space M itral- 5th intercostal space at midclavicular Palpate carotid and temporal pulses bilaterallyshould be palpable and regular in rhythm A P E TM Abdomen Assess bladder and voiding habits Inspect contour and symmetry Auscultate for bowel sounds Start in RLQ and go clockwise Absent (must listen for 5 min) Hypoactive Normoactive Hyperactive Auscultate for bruits using the BELL of the stethoscope Aorta Renal Iliac Femoral Percuss all 4 quadrants Palpate all 4 quadrants and assess for rebound tenderness RUQ LUQ RLQ LLQ Upper and Lower Extremities Assess ROM and strength Check cap refill on fingernails and toenails Assess sharp and dull sensations Palpate radial and brachial pulses Palpate femoral, popliteal, posterior tibialis, and dorsalis pedis pulses Assess gait Check for edema Test DTR Downloaded by Salv Fuent (salv.chamizo@gmail.com) Grade 0 1+ 2+ 3+ 4+ Depth 0 1/4 inch 1/4-1/2 inch 1/2-1 inch > 1 inch
