basic head to toe assessment

Christi Scott, RNChristi Scott, RN

By the end of this presentation, students will be able to: 

Demonstrate where to listen for an apical pulse..

Demonstrate proper technique for listening to breath sounds.

Demonstrate how to assess for pitting edema.

List the three ways to assess the patient’s mental status and orientation.

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Knock and introduce yourself. Wash your hands and don gloves prior

to touching the patient. Establish rapport by using eye contact. Sit at the level of the patient if possible . Explain all procedures to the patient

prior to performing them.

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Vital Signs

Pulse Rate, Strength, RegularityTemperature________ Oral, Rectal,

TympanicRespiration_______________

B / P_________Pain Assessment _________________Oxygen saturation ________________

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Assessing For Pain (PQRST method)

P – Provokes, palliative measureQ – Quality (describe)R – Region, radiate?S – Severity, on a scale of 0 - 10T – timing, when did it start? How long

does it last?

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Orientation – time, person, place, reason

Can you tell me your name ? _______________________Can you tell me where you are ? ____________________Do you know what today's date is?__________________

Pupil Check

( PERRLA ) Pupils, Equal, Round, React to light, Accommodate

Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )Accommodation Yes ( ) No ( )

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Neck VeinsPatient at 45 degree angle ( )Neck Veins Flat ( ) Distended ( )

Neck veins should be checked by having Neck veins should be checked by having the patient sit at a 45 degree angle. In this the patient sit at a 45 degree angle. In this position, the jugular veins should be flat. position, the jugular veins should be flat.

Distended neck veins at 45 degrees are an Distended neck veins at 45 degrees are an indicator of over hydration or fluid indicator of over hydration or fluid overload. overload.

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Edema, or fluid in the tissues tends to go to dependent areas of the body. This may be the hands, feet or sacrum.

To check for edema push your finger down on the foot over the distal end of the tibia and observe for indentation or pitting.

1+ slight pitting, no visible distortion, disappears rapidly

2+ somewhat deeper pit than 1+, no readily detectable distortion, disappears in 10-15 sec.

3+ pit noticeably deep, may last more than a minute; the dependent extremity looks fuller and swollen.

4+ pit very deep, lasts 2-5 min; dependent extremity is grossly distorted.

Heart TonesApical Pulse with StethoscopeRate ?_____________ Rhythm ? ___________Clarity of Sounds ? _________ Abnormal ? Explain ! ____________________________

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Ape(Apical and Pulmonic)

To(Tricuspid)

Men

(Mitral)

Heart tones are checked by listening to the apical pulse for a total of one minute.

This pulse is auscultated with the bell of the stethoscope.

Check the apical pulse for rate, rhythm, and clarity of the sounds of the S1 and S2 otherwise known as "lub and dub".

Any abnormalities should be reported.

Bilateral Pulse Checks ( Radial Pulses ) - Rate, Strength, Regularity

Right_____________ Left______________ ( Pedal Pulses – DP/PT ) - Top of Foot

Right Foot __________ Left Foot ____________ ( Capillary Refill ) - On fingers or toes 3

seconds or lessRight Fingers ( ) sec. Left Fingers ( ) sec. Right Toes ( ) sec. Left Toes ( ) sec.

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Dorsalis Pedis

(To locate pulse draw a straight line back from the patients

great toe to the middle of the dorsum of the foot)

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Breath Sounds Assess anterior and posterior and from side

to side, left to right lobe using the diaphragm of the stethoscope.

Have patient take deep breaths, do not move stethoscope to rapidly to avoid hyperventilation.

Have the patient take deep breaths in and out of their mouth as nose breathing can create air turbulence that may alter the sounds.

Breath sounds should be clear bilaterally with good air flow.

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Normal breath soundsBronchial sounds - Pitch: High. Intensity: Loud,

predominantly on expiration. Normal findings: A sound like air blown through a hollow tube

Bronchovesicular sounds - Pitch: Moderate. Intensity: Moderate. Normal findings: A blowing sound heard over airways on either side of sternum, at angle of Louis, and between scapulae

Vesicular sounds - Pitch: High on inspiration, low on expiration. Intensity: Loud on inspiration, soft to absent on expiration. Normal findings: Quiet, rustling sounds, heard over periphery

ADVENTITIOUS SOUNDS

Fine Crackles (Rales) Over lung fields and airways; heard in lung bases first with pulmonary edemaMore audible during inspirationCause: Moisture, especially in small airways and alveoliSounds like Rice Crispies Cereal.

Rhonchi / Coarse CracklesHeard larger airways.More pronounced during expirationCaused bronchospasm or secretionsSounds like rattling, usually louder and lower-

pitched than fine crackles. Clears with coughing.

WheezesHeard over lung fields and airwaysInspiration or expirationCaused bronchospasm Sounds like a high pitched whistle

Pleural Friction RubHeard at front and side of the lung fieldsInspirationCause by the inflamed parietal and visceral pleural surfaces rubbing together.Sounds like grating or squeaking.

Bowel Sounds Assess all 4 quadrants, do not touch stomach before

auscultation, as it may disrupt normal sounds. If irregular,

1 minute assessment on each quadrant to accurately record no bowel sounds present.

( Stomach ) – Inspect and palpate for conditionSoft ( ) Hard ( ) Distended ( ) Other

RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( ) LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )

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Ask the patient about:Urgency, burning, incontinence and pain.

Assess:Catheter, drainage, urine output.

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Skin Skin Turgor - 1 to 3 second return on the

dorsum of the hand. Skin Color - Check on inside of Lip or

ConjunctivaLip ( ) Conjunctiva ( )Pink ( ) Pale ( ) Jaundice ( )

Skin Temperature - Use back of hand to checkHot ( ) Warm ( ) Cool ( )

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0 No defection of muscular contraction

1 A barely detectable flicker or trace of contraction with observation or palpation

2 Active movement of body part with eliminations of gravity

3 Active movement against gravity only and not against resistance

4 Active movement against gravity and some resistance

5 Active movement against full resistance without evident fatigue (normal muscle strength)