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  • HA: Head to Toe Assessment - Becoming Bri€¦ · HA: Head to Toe Assessment PT LAYING/SUPINE 5. ABDOMEN Inspect: a. Skin, Facial expression b. Symmetry & Shape c. Contour Auscultate:
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HA: Head to Toe Assessment Intro, pt privacy, hand hygiene, PPE 1. GENERAL SURVEY (L,A,H,H,P,P,S,S) a. LOC/A&O b. Age c. Health & Hygiene d. Physique & Posture/gait e. Speech & Sex 2. SKIN a. Color b. Temp. c. Moisture d. Pigmentation e. ABCDE 3. HEAD Inspect: a. size, shape, hair distribution b. scalp for lesions or pests Palpate: a. Temp. Arteries bilaterally b. TMJ (no crepitus/tenderness/LOM) c. Neck symmetry and lumps d. Trachea midline e. Thyroid gland f. No JVD g. CN 5 h. CN 7 i. Skin turgor Palpate Sinuses o Frontal sinus o Maxillary sinus Palpate Lymph nodes 1. Preauricular 2. Post auricular 3. Jugulodigastric 4. Submandibular 5. Submental 6. Occipital 7. Superficial cervical 8. Posterior cervical 9. Deep Cervical 10. Supraclavicular Otoscope for Ears & Nostrils Occlude Nostrils (one at a time- breathe in) PERRLA c. Pupils Equal Round and Reactive to Light and Accommodation d. Follow penlight in H formation e. Accommodation Open Mouth w/ penlight f. Mucous membrane g. Tongue (9,10,12) Shoulders h. CN 11- shoulder shrug and resistance on face upon turning 4. CARDIO & LUNGS Inspect: a. Skin, Facial expression b. Resp. Characteristics (L) c. Symmetry & Shape (B) d. AP Ratio (L) Palpate: a. Chest wall (B) b. Heaves or palpable thrills (CV) c. Tactile fremitus (L)* d. Symmetrical expansion (L) Auscultate: a. APETM b. Murmurs c. PMI (rate/rhythm) d. 10 anterior (L) – B/BV/V** e. 8 posterior (L)** f. Bronchophony (L)* g. Symmetrical expansion (L)** h. PALPATE spinous processes

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Page 1: HA: Head to Toe Assessment - Becoming Bri€¦ · HA: Head to Toe Assessment PT LAYING/SUPINE 5. ABDOMEN Inspect: a. Skin, Facial expression b. Symmetry & Shape c. Contour Auscultate:

HA: Head to Toe Assessment

Intro,ptprivacy,handhygiene,PPE

1. GENERALSURVEY(L,A,H,H,P,P,S,S)a. LOC/A&Ob. Agec. Health&Hygiened. Physique&Posture/gaite. Speech&Sex

2. SKINa. Colorb. Temp.c. Moistured. Pigmentatione. ABCDE

3. HEADInspect:

a. size,shape,hairdistributionb. scalpforlesionsorpests

Palpate:a. Temp.Arteriesbilaterallyb. TMJ(nocrepitus/tenderness/LOM)c. Necksymmetryandlumpsd. Tracheamidlinee. Thyroidglandf. NoJVDg. CN5h. CN7i. Skinturgor

PalpateSinuseso Frontalsinuso Maxillarysinus

PalpateLymphnodes1. Preauricular2. Postauricular3. Jugulodigastric4. Submandibular5. Submental6. Occipital7. Superficialcervical8. Posteriorcervical9. DeepCervical10. Supraclavicular

OtoscopeforEars&NostrilsOccludeNostrils(oneatatime-breathein)PERRLA

c. PupilsEqualRoundandReactivetoLightandAccommodation

d. FollowpenlightinHformatione. Accommodation

OpenMouthw/penlightf. Mucousmembraneg. Tongue(9,10,12)

Shouldersh. CN11-shouldershrugandresistanceon

faceuponturning4. CARDIO&LUNGSInspect:

a. Skin,Facialexpressionb. Resp.Characteristics(L)c. Symmetry&Shape(B)d. APRatio(L)

Palpate:a. Chestwall(B)b. Heavesorpalpablethrills(CV)c. Tactilefremitus(L)*d. Symmetricalexpansion(L)

Auscultate:a. APETMb. Murmursc. PMI(rate/rhythm)d. 10anterior(L)–B/BV/V**e. 8posterior(L)**f. Bronchophony(L)*g. Symmetricalexpansion(L)**h. PALPATEspinousprocesses

Page 2: HA: Head to Toe Assessment - Becoming Bri€¦ · HA: Head to Toe Assessment PT LAYING/SUPINE 5. ABDOMEN Inspect: a. Skin, Facial expression b. Symmetry & Shape c. Contour Auscultate:

HA: Head to Toe Assessment

PTLAYING/SUPINE

5. ABDOMENInspect:

a. Skin,Facialexpressionb. Symmetry&Shapec. Contour

Auscultate:4QsPercuss**:

a. 4QsofAbdomenb. Lungsc. Liver

Palpate:4Qs(LightthenDeep)Specialtests:

a. Murphys(Holdliver)*b. KidneySqueeze*c. Blumberg/Rebound(deeppalpation/release)*

6. BLEa. Skin,hair,temp.,symmetryb. Toeclubbing,lesions,toecap.Refill**c. Edemad. Leg/Feetsensatione. AskinsteadofdoingHomans*f. ROMforlegs/hipsg. BangHeel(shootingpain,DF/PF)*h. BabinskiReflex*

ROMtestsforlegs(seevideofortechnique)

BRINGPTUPMANUALLYTOWATCHJVD

7. PULSESa. FingerCapRefillb. Radialc. Brachial**d. Mod.Allen’sTest(releaseulnarartery)*e. EpitrochlearNodesf. Popliteal**g. Tibialh. Dorsalispedis**

8. BUEa. Sterognosis&graphosis*b. Fingerresistancec. Squeezemyfingerd. PushandPullArmse. Behindbackandpushwithhandsf. ChintoNeck/back/sides

9. REFLEXES*a. Biceps&Triceps*b. Brachio*c. PatellarandAchilles*

PTSTANDING

10. Balancetestsa. Heeltoshinb. Closeeyesandeachfingertonosec. Shakewhileeyesclosed*openeyesafter*d. Armsoutandupbehindheade. Touchtoesandbendbackwardsf. Squatg. Duckwalkawayh. Walkheeltotoebacki. Walkonheels/toesj. Kneetochestandkneebackk. Spinetwist


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