Head-to-Toe Assessment
Unit One
Head-to-toe assessment
review
Objective One
Demonstrate head to toe
assessment of the adult
client
Physical Examination Techniques
 Inspection = observation of the client (may at times
include use of penlight, otoscope, and/or
ophthalmoscope)
 Palpation = use of touch to assess client
 Use light pressure first to assess body surface
 Next use deep palpation to assess underlying structures
 Assess areas of pain/tenderness/discomfort last
 Percussion = tapping fingers on the client’s skin
using short strokes to assess underlying structures to
determine size/density/location
 Auscultation = use of hearing to assess client
Types of
Percussion and Auscultation
 Percussion - Direct percussion involves tapping lightly with the pads of
the fingers directly on the client’s skin
 Indirect percussion involves use of both hands; strike the
stationary finger like a hammer to produce the best sound
 Auscultation - Direct auscultation involves listening to the client without
using an assistive instrument (i.e. wheezing, chest
congestion)
 Indirect auscultation involves listening to the client with the
use a stethoscope
Assessment of 5 Percussion Notes
 Flatness = soft intensity, high pitch, short duration
 Heard over solid areas (muscle)
 Dullness = medium intensity, medium pitch, medium
duration
 Heard over fluid-filled areas
 Resonance = loud intensity, low pitch, long duration
 Normal lung sound
 Hyper resonance = very loud intensity, lower pitch,
longer duration
 Heard over hyperinflated areas (emphysema)
 Tympany = loud intensity, high pitch
 Heard over air-filled areas (gastric air bubble)
General Survey
*Begins at first contact with the client and continues
throughout the exam
*Provides an overall impression of the client/client
system
 Appearance and behavior
 Appears stated age
 Speech/behavior appropriate to developmental stage
 Facial expressions
 Physical/emotional distress
 Skin color
 Vision and hearing
 Glasses, hearing aid, etc
General Survey (cont’d)
 Speech
 Appropriate, logical
 Tone, speed, and clarity
 Vocabulary/grammar
 Body type and posture
 Body size/build
 Mobility, gait, and coordination
 Physical deformities
 Range of motion
 Dress, grooming, and hygiene
 Poor hygiene/unkempt
 Manner of dress appropriate for climate
General Survey (cont’d)
 Mental status
 Level of consciousness
 Orientation
 Mood, affect
Affect is the emotional state as it appears to others. Mood is the
emotional state as described by the patient. Observe the patient's
facial expression. No part of the body is as expressive as the face.
Feelings of joy, sadness, fear, surprise, anger, and disgust are
conveyed by facial expression. Facial expressions generally are not
consciously controlled.
 Interaction
 Vital signs
 T/P/R and BP
 Pain assessment
 Allergies
 Height and weight
 Nutritional status
 Unexplained weight loss

Skin Assessment
 Skin characteristics
 Temperature


Compare upper and lower extremities, and bilaterally
Excessive warmth may indicate fever, whereas excessive coolness
may indicate poor circulation, shock, or hypothyroidism
 Moisture

Should be warm and dry (but excessively dry skin may indicate
dehydration)
 Color



Varies per age, culture, ethnicity
Mongolian spots = blue-black areas that are sometimes present
on the lower back or buttocks of African American, Native
American, and Asian babies
Capillary hemangiomas (‘stork bites’) = small, irregular pink-red
areas present around the face/neck of newborns
Common Skin Color Variations
Color
Variation
Description
Significance
Pallor
Loss of pink/yellow tones
or extreme paleness in
light-skinned clients
Loss of red tones in darkskinned clients
Poor circulation, low hemoglobin level
Assess via oral mucosa, conjunctiva, nail beds, soles
of feet, palms of hands
Cyanosis
Blue-gray coloration of
the skin; ashen
Central cyanosis is R/T hypoxia
May be seen in extremities after exposure to
extreme cold
Jaundice
Yellow-orange cast to the
skin
Associated with liver disorders
Assess via sclera, oral mucosa, palms and soles
Flushing
Widespread, diffuse area
of redness
Results from fever, excessive room temperature,
sunburn, polycythemia, vigorous exercise
Erythema
A reddened area
Associated with rashes, skin infections, prolonged
pressure on the skin
Ecchymosis Bruised (blue-green-
Bruising may indicate physical abuse
Petechiae
Extravasation of blood into the skin
May be associated with a disorder or medication
yellow) area
Tiny, pinpoint red or
reddish-purple spots
Skin Assessment (cont’d)
 Skin characteristics (cont’d) - Texture


Should be smooth and soft
May be affected by exposure, age, endocrine disorder, and
impaired circulation
 Turgor


Refers to the elasticity of the skin, and indicates hydration status
Skin that takes 3 seconds or longer to return to its original
position is termed ‘tenting’, and indicates dehydration
 Lesions



Primary = result of disease or irritation
Secondary = develops from primary lesions as a result of
continued illness, exposure, injury, or infection
Evaluate for size, shape, pattern, tenderness, pain, etc
Skin
 Nodule--a solid mass extending into the dermis.
 (2) Tumor--a solid mass larger than a nodule.
 (3) Cyst--an encapsulated fluid-filled mass in the
dermis or subcutaneous layer.
 (4) Wheal--a relatively reddened, flat, localized
collection of fluid. An example is hives.
 (5) Vesicle--circumscribed elevation containing
serous fluid or blood. An example is chickenpox.
 (6) Bulla-- large fluid-filled vesicle. An example is
a second-degree burn.
 (7) Pustule--a vesicle or bulla filled with pus. An
example is acne.
Assessing Pitting Edema
Trace Minimal depression noted when pressure applied
+1
Application of pressure creates a depression of about 2 mm; no visible distortion; rapid
return of skin to position
+2
Application of pressure creates a depression up to 4 mm in depth that disappears in
about 10-15 seconds
+3
Application of pressure creates a depression of approximately 6 mm in depth that lasts
about 1-2 minutes; area appears swollen
+4
Application of pressure creates a depression up to 8 mm in depth that persists for about
2-3 minutes; area is grossly edematous
 Skin characteristics (cont’d) - Edema



Excessive amount of fluid in the tissues
Common in congestive heart failure, kidney disease, peripheral
vascular disease, or low albumin levels
Pitting edema is graded on a 0 to +4 scale
Assessing the Hair
 Assess for color, texture, condition, and distribution
 Pediculosis = head lice infestation
 Nits (lice eggs) may be found on the hair shaft close to the
scalp
 Alterations in hair distribution may be the sign of
disease
 Alopecia = hair loss


Chemotherapy
Nutritional deficiencies
 Hirsutism = excess facial or trunk hair


Endocrine disorders
Steroid use
 Assess scalp (dandruff, dermatitis, psoriasis, etc)
Assessing the Nails
Condition of Nail/Nail Bed
Indications or Concerns
Pale or cyanotic beds
Circulatory or respiratory disorders that result in anemia or
hypoxia
Half-and-half nails
Appears as a distal band of reddish-pink that covers 20-60% of
the nail; caused by low levels of albumin or renal disease
Mee’s lines
Appears as transverse white lines in the nail bed; results from
severe illness
Splinter hemorrhages
Small hemorrhages under the nail bed that are associated with
bacterial endocarditis or trauma
Black nails
Related to blood under the nail--occurs after a local trauma
White spots
Zinc deficiency
Clubbing
Refers to an angle of the nail bed that is 180° or more (normal is
160°); associated with hypoxic states (i.e. chronic lung disease)
Spooning
Iron deficiency
Thickened nails
Poor circulation or fungal infection
Brittle nails
Hyperthyroidism, malnutrition, calcium and iron deficiency
Soft, boggy nails
Poor oxygenation
Vital Signs
 Body temperature
 Wait for 15-30 minutes after the client smokes or
eats/drinks something hot/cold before taking an oral
temperature
 Respirations
 Count unobtrusively for 30 seconds if respirations are
regular, and for 60 seconds if they are irregular
 Observe rate, rhythm, and depth of respirations
 Blood pressure
 Client should be seated with both feet on the floor
 Client should be inactive for 5 minutes before measuring
 Use correct cuff size, and support the client’s arm at the
level of his heart
Vital Signs (cont’d)
 Assess apical pulse
 Palpate 5th intercostal space at the midclavicular line for
stethoscope placement
 Count for 60 seconds
 Note pulse rate, rhythm, and quality, as well as the S 1 and
S2 heart sounds
 Assess radial pulse
 Make sure client is resting while assessing the peripheral
pulse
 Palpate appropriate site, counting for 30 seconds if the
pulse is regular, and for 60 seconds if the pulse is irregular
 Compare pulses bilaterally
Assessing the Head
 Observe symmetry of features, facial expressions
 Abnormal facial features may indicate genetic or chronic
disorder (i.e. Graves’ disease, hypothyroidism/myxedema,
Cushing’s syndrome)
 Assess jaw motion for clicking, pain, or crepitus, which
may indicate temporomandibular joint syndrome (TMJ)
 Measure head circumference if indicated
 Acromegaly, a disorder of excessive growth hormone, may
result in enlarged head in adolescents and adults
 Microcephaly is an abnormally small head size that may
accompany mental retardation
 Hydrocephalus may present in infants and children,
indicating an accumulation of excessive cerebrospinal fluid
Assessing the Eyes
 External structures
 PERRLA (pupils equal, round, reactive to light and
accommodation)
 Conjunctiva: smooth, glistening , and ‘peach’ in color
 Sclera: smooth, glistening, and blue-white in color
 Cornea: transparent, smooth, and moist
 Visual acuity
 Snellen chart measures distance vision

Myopia = diminished distance vision
 Near vision measured by having client read newsprint from
a distance of 14 inches


Hyperopia = diminished near vision
Presbyopia = decrease in near vision due to the aging process
Assessing the Ears
 Otic structures
 External ear = collects and conveys sound waves; protects
the middle ear from the external environment

Otitis externa = infection of the outer ear that may result in a
painful auricle or tragus
 Middle ear = consists of the tympanic membrane,
eustachian tube, and the ossicles; conducts sound waves
from the external ear to the inner ear

Otitis media = middle ear infection that may present as
tenderness behind the ear
 Inner ear = hearing and equilibrium
 Cerumen (ear wax) should be present, but should not
occlude the ear canal
 May be black, dark red, gray, or brown in color
Assessing the Nose
 Sinus areas should be nontender upon palpation
 Nasal passages should be pink and moist, and free from
drainage or lesions
 Septum should be symmetrical
 Assess client’s ability to breathe freely through both sides
of the nose
 Sense of smell is diminished in older adults due to
atrophy of olfactory nerve fibers
Assessing the Mouth and Neck
 Buccal mucosa should be smooth, moist, and pink:
Common Buccal/Oral Variations
Condition of Mouth/Oral
Mucosa
Indications or Concerns
Paleness
Anemia or inadequate oxygenation
Canker sores
Painful vesicles that erupt with allergies and stress
Gingivitis
Red, swollen or spongy, bleeding gingiva with receding gum lines;
tenderness may be present; this is a sign of periodontal disease
Parotitis
Inflammation of the parotid salivary gland
Stomatitis
Inflammation of the oral mucosa
Leukoplakia
Thick, elevated white patches that do not scrape off; may be
precancerous lesions
Thrush
White, curdy patches that scrape off and bleed caused by a
fungal infection
Aphthous ulcers
Small, painful vesicles with a reddened periphery and white/pale
yellow base; caused by viral infection, stress, or trauma
Mouth and Neck Assessment (cont’d)
 Mouth/lips should be symmetrical
 Assess for swelling or drooping
 Assess for difficulty swallowing
 Assess teeth for dentures, obvious caries, loose teeth
 Tongue should be moist, symmetrical, slightly rough,
smooth, pink, and freely movable
 Abnormal findings include deviation from midline; glossitis
(inflammation of the tongue); limited mobility; dry, furry
tongue related to dehydration; black, “hairy” tongue
associated with fungal infections; swelling, nodules, or
ulcers
 Palpate neck for tenderness/nodules, thyroid
 Inspect for swelling, ROM
Lung Assessment
 Alterations in respiratory rate
 Bradypnea = slow respirations (<10 breaths/minute)
 Tachypnea = fast respirations (>24 breaths/minute)
 Alterations in respiratory effort
 Dyspnea = labored breathing
 Orthopnea = inability to breath in the horizontal position
 Abnormal breath sounds
 Wheezes = high-pitched, continuous musical sounds


Usually heard on expiration
Caused by narrowing of the airways
 Rhonchi = low-pitched, continuous sounds


Caused by secretions in the large airways
Often clears with coughing
Lung Assessment (cont’d)
 Abnormal breath sounds (cont’d) - Crackles = discontinuous sounds that may be high-pitched,
popping sounds (fine crackles), or low-pitched, bubbling
sounds (course crackles)

Usually heard on inspiration
 Stridor = piercing, high-pitched sound


Primarily heard during inspiration
Indicates respiratory distress
 Stertor = labored breathing that produces a snoring sound
 Retraction refers to the visible sinking of tissues around
and between the ribs, sternum, or clavicles due to
respiratory difficulty
 Note clubbing, coughing, and signs of hypoxia
Cardiovascular Assessment
 Observe the precordium (area of the chest over the heart)
for pulsations or heaves
 Abnormal anywhere except at the 5th ICS MCL (‘point of
maximal impulse’, or PMI)
 Associated with an enlarged ventricle
 Palpate for ‘thrill’ (vibration or pulsation) over the chest
 May indicate abnormal blood flow and/or presence of a
heart murmur
 Assess circulation
 Palpate peripheral pulses
 Check capillary refill
 Assess Homan’s sign or calf tenderness
 Assess extremities for peripheral edema
Cardiovascular Assessment (cont’d)
 Blood pressure
 Cuff width should cover approximately 2/3 of the length of
the upper arm for an adult, and the entire upper arm for a
child


Incorrect cuff size can result in measurement error of up to
30mmHg
Using a cuff that is too large is better than using one that is too
small
 Use the popliteal artery if brachial arteries unavailable

Systolic pressure may be 20-30mmHG higher in the lower
extremities, but diastolic pressure should be the same
 Auscultate apical rate and rhythm
 Listen to apical pulse for full minute
 Compare apical pulse to radial pulses
Assessment of the Extremities
 Assess for musculoskeletal abnormalities, as major
deformities may affect posture and gait
 Kyphosis = accentuated thoracic curve
 Scoliosis = lateral ‘S’ deviation of the spine
 Lordosis = accentuated lumbar curve
 Assess balance and movement by having client
tandem walking, heel-and-toe walking, deep knee
bends, and hopping in place
 Assess coordination via finger-thumb opposition and
having client run the heel of one foot down the shin
of the other
 Movements should be smooth and controlled
Extremity Assessment (cont’d)
 Joints should be smooth, nontender, warm to the
touch, and of similar color to surrounding tissue
 Color changes may indicate inflammation or infection
 Assess effect on joint function


Active ROM
Passive ROM
 Crepitus = clicking or grating at the joint
 Assess muscle strength by applying resistance while
client is performing active range of motion exercises
 Should be strong and equal bilaterally
 Test ‘hand grasp’ strength and ‘foot push’ strength
 Both should be equal bilaterally
Assessment of the Genitourinary System
 The GI system consists of the external genitalia,
rectum, urethra, bladder, kidneys, ureters, and
prostate in males
 Circumcision = excision of the foreskin of the penis


No longer recommended as routine practice
Parental preference remains widespread
 Hernia = protrusion of the intestine or other organ


Typically found in the inguinal area in males
May cause pain and distention
 Hemmorrhoids = dilated, painful anal vessels

Commonly seen in pregnancy, childbirth, constipation
 Assess for problems or changes in voiding
Objective Two
Document findings by
narrative charting
Narrative Charting
 Tells the story of the patient’s experience in a
chronological format
 Goal = track client’s changing health status and
progress toward positive outcomes
 Especially useful in constructing a timeline of events
(i.e. cardiac arrest, etc)
 Requires the writing out of the details of the patient’s
care in sequence
 Be sure to organize your thoughts prior to beginning
your documentation, as it can be easy to ramble in
narrative charting
Unit Two
Physical assessment
techniques for the lungs
and abdomen
Objective One
Demonstrate the
assessment technique of
light palpation and
percussion to abdomen
Examination of the Abdomen
 Inspect and auscultate the abdomen first in order to
avoid stimulating/altering bowel sounds through
percussion/palpation; bladder should be emptied
prior to examination
 Auscultate bowel sounds in all 4 quadrants of the
abdomen
 Discontinue NG suction (or clamp tube) if indicated
 Absent bowel sounds = no sound auscultated after listening
for 5 minutes
 Hypoactive bowel sounds = very soft and infrequent (i.e. 1
sound per minute)
 Hyperactive bowel sounds = loud, rushing sounds occurring
every 2-3 seconds
Examination of the Abdomen (cont’d)
 Palpation of abdomen
 Use light palpation (pads of fingertips) to evaluate for
tenderness and guarding, superficial masses

Involuntary rigidity of the abdominal muscles may indicate
peritoneal inflammation
 Use deep palpation to assess organs (this is an advanced
technique that is not usually performed by staff nurses)


Liver border should be smooth and free of masses
Should not be able to palpate the spleen
 Abdominal percussion should be primarily tympanic
 Liver should be dull over right MCL
 Stomach should be tympanic at left lower anterior ribcage
 Spleen should be dull near left 10 th rib posterior to MAL
Objective Two
Demonstrate the
assessment technique of
percussion of the thorax and
abdomen
Examination of the Thorax
 Thorax = formed by the ribs, sternum, and vertebrae;
protects the heart, lungs, and great vessels
 Assess with client in sitting position
 Observe sternal angle
 Rib slope should be less than 90°
 Estimate chest diameter
 Anteroposterior diameter should be twice the size of transverse
diameter
 ‘Barrel chest’ (equal diameters) often seen with COPD
 Osteoporosis may shorten length of spine, pushing ribs forward and
downward
 Light palpation of the lungs (perform both anterior and
posterior assessment)
 Assess symmetry of respiratory movement by having client
inhale deeply while grasping the lateral ribcage with thumbs
level to the 10th ribs
Examination of the Thorax (cont’d)
 Palpation of the lungs (cont’d) --
 Assess for tactile fremitus by having client repeat the words
‘99’ while using palm of hand to palpate chest and back



Identify areas of increased or decreased fremitus
Fremitus is decreased (or absent) if the bronchus is obstructed or
there is fluid in the pleural space
Fremitus is increased near large bronchi and over consolidated lung
tissue (i.e. pneumonia)
 Percussion of the lungs
 Assess if underlying tissues are air-filled, fluid-filled, or solid
 Identify level of diaphragmatic dullness bilaterally during
respiration per posterior percussive assessment



Have client fold arm across chest and percuss across the top of
each shoulder to identify lung apex
Percuss symmetrical areas of lung while moving down client’s back
Percuss areas along the sides beneath the scapulae and down the
middle of client’s back
Examination of the Thorax (cont’d)
 Percussion of the lungs (cont’d) --
 Systematically move down the chest wall for anterior
percussion assessment
 Should percuss dullness over the heart (left of the sternum
from the 3rd to the 5th interspaces)

Dullness replaces resonance when fluid or solid tissue replaces air
 Abnormally high dull sounds indicate pleural effusion or
atelectasis

Only a large amount of pleural effusion can be detected per
anterior percussion because fluid displaces posteriorly when client
is in the supine position
 Identify upper border of the liver by percussing dullness to
the right of the thorax
 Identify tympanic gastric air bubble via percussion to the left
of the thorax
Unit Three
Physical assessment
techniques for the eye, ear,
and nose
Objective One
Demonstrate the proper use
of the ophthalmoscope
Examination via Ophthalmoscope
 Perform examination in a darkened room
 Switch on ophthalmoscope light; turn lens disc to 0
 Keep index finger on lens disc to facilitate refocusing
during assessment; use right hand when examining client’s
right eye, and left hand when examining client’s left eye
 Use large round beam (0) for large pupils
 Use small round beam for small pupils
 Use green/red beam to detect lesions
 May use thumb of opposite hand on client’s eyebrow to
guide movement, and to gently ‘lift’ upper lid if needed
 Have the client look straight ahead at a specific point on
the wall; hold scope firmly against your own face with your
eye directly behind the sight hole
 Hold scope 15 inches away, and about 15˚ lateral to
client’s line of vision; shine beam of light on the pupil
Ophthalmoscopic Exam (cont’d)
 Identify optic disc
 Should be yellowish orange, oval or round
 Should note branching of vessels away from the optic disc,
and progressive enlargement of vessel size as the vessels
approach the disc
 Disc outline should be clear
 Lens should be transparent
 Assess for the ‘red reflex’ (orange glow)
 Absence may indicate cataract, detached retina, or artificial
eye
 Keep light beam focused on the red reflex as you move
ophthalmoscope closer to the pupil
 Identify arterioles and veins
 Arterioles are light red, smaller, with bright light reflex
 Veins are dark red, larger, with absent light reflex
Ophthalmoscopic Exam (cont’d)
 Adjust lens disc
 Use clear glass lens for normal-sighted client
 Use lens with longer focus and rotate lens disc
counterclockwise (minus diopters, or red numbers) for
nearsighted client
 Rotate lens disc clockwise (plus diopters, or black numbers)
for farsighted client
 Rotate progressively to +10 to +12 diopters to focus on the
anterior structures of the eye
 Observe macular area (which is responsible for central
vision) by having client look directly into the beam
 Identify retinal abnormalities
 Flame-shaped hemorrhages may indicate hypertension
 Large, horizontal line may indicate preretinal hemorrhage
 Tiny red spots are indicative of diabetic retinopathy
Glaucoma
Cataract
Retinal Detachment
Conjunctivitis
Stye
Diabetic
Retinopathy
Objective Two
Demonstrate the proper use
of the otoscope
Otoscopic Examination
 Ear Assessment




Perform examination in a darkened room
Use the largest speculum the ear canal can accommodate
Have the client tilt head toward the side not being examined
Pull the helix up and back for adults, and down and back for
children under the age of 5

May be painful in clients with acute otitis externa
 Insert speculum into outer 3rd of the ear canal; gently
manipulate position to visualize the entire drum


Observe for wax build-up, discharge, foreign body, redness or
edema
Assess for ‘cone of light’ and bony landmarks (i.e. the ‘handle’ and
a portion of the malleus)
 Nasal Assessment
 Use short, wide nasal speculum
 Observe lower portions of the nose, then the upper portions
Otoscopic Examination (cont’d)
 Assessing the Nose (cont’d) --
 Use short, wide nasal speculum
 Observe lower portions of the nose, then the upper portions
 Assess the nasal mucosa
 Should be slightly more red than oral mucosa
 Observe for edema, exudates, or bleeding
 Inspect the nasal septum for bleeding or deviation (deviated
septum is common in clients with chronic allergies, history of
broken nose, etc)
 Observe the inferior and middle turbinates and middle
meatus for edema, exudates, and polyps; note color
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Objective Three
Assess the anatomical
structures visible with the
ophthalmoscope/otoscope
(*Lab Practice)