head to toe assessment e.n. 208a

8/3/2019 Head to Toe Assessment E.N. 208A

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Assessment/Brittany 1

Head to Toe Assessment

Brittany Wood

Patrick Henry Community College

NUR 111

April 2, 2010


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Head to Toe Assessment

E.n. is a 90 year old, Caucasian, female, approximately 5 feet 9 inches in height. Weight

is 85 kilograms (187 pounds), widowed with 2 children. Admitted to the facility (STHC) 3/09/10

to rehabilitation unit, previous admission 12/04/07, also for rehab care related to right stroke.

Medical history consists of hypertension, mild noninsulin-dependent diabetes mellitus, previous

(remote) right sided stroke, osteoarthritis with degenerative lumbar spine, and mild

hypercholesterolemia. Surgical history includes cholecysectomy, left ankle fracture with

fixations (1980s). Drug allergy to penicillin and Triaminic syrup. On arrival to room 208A,

client was awake with a smile. In the bed with legs elevated 30 degrees. Pleasant and welcoming

demeanor with adequate conversation. Vital signs T: 97.4, P: 78, RR: 14, B/P: 159/62, O2 sat:

93%. Smooth and coordinated, steady motion upon standing to transfer to chair.


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Integumentary assessment consists of intact skin, dryness, and 3 plus pitting edema.

Edema most prominent of lower portion of legs bilaterally. Deep red almost purple in color with

excessive dryness noted. Legs were to be elevated while in sitting or lying positions. Bruises

noted on forearms and abdomen. Abdomen bruising had greatly subsided and was barely visible.

Skin was pink in color, warm and dry to the touch. Clean with no odors present.

Hair is resilient and evenly distributed. No presence of infestations, scaling, or oiliness.

Small amount of body hair present on upper extremities bilaterally. Daily grooming consists of

brushing or coming, washes only on bath days. Hair clean all well kept no odor present.

Nails on hands were convex with no noted grooving or clubbing. Skin around nail bed

was dry but still intact. Toenails were long, thick, and yellow in color. No sign of infection or

odor. Capillary refill is less than 4 seconds on both hands.

Head assessment reveals normocephallic skull shape. No lesions, nodules, or lumps

noted. No tenderness when palpated. Symmetrical facial features and expressions. Exopthalmus

not present on inspection. No edema or redness noted.

Eyes are dark blue in color. Slight ptosis noted. Wears glasses that contain bifocals. Able

to clearly with the use of corrective lenses only. Eye movement equal bilaterally. PERRLA,

pupil size 3-4 mm while in room with the light on.

Ear assessment shows no signs of infection or tenderness. Pliable with no redness or

nodules palpable. Uniform in color with no drainage present. Symmetrically aligned with outer

canthus of eyes bilaterally. External meatus open and clean with small amount of dry grayish

crumen present. Normal voice tones inaudible. Unable to hear a whisper up close to the ear. No

hearing aid devices noted.


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Nose assessment reveals symmetric and straight alignment. No deviations to septum noted.

Septum is intact and midline with no noted drainage. Internal mucosa is pink and moist with no

redness present upon inspection of nares. Keen sense of smell when alcohol swab placed near

nose. Patent airway bilaterally (use of nasal canula if O2 sat is less than 90%). Frontal and

maxillary sinuses not tender upon palpation.

Lips are thin and smooth with small amount of dryness noted. No dentures are present.

Hard and soft palate is pink with no presence of irritation or redness. Bottom teeth are crowded

with retraction of gums noted on lower gum area. Tongue is pink and midline with no signs of

infection or lesions present. Uvula is present and midline.

Assessment of the neck reveals symmetrical strength and adequate range of motion

bilaterally (able to extend, hyperextend, and flex). No tenderness or nodules present upon

inspection and palpation. Thyroid gland is not visibly enlarged. Lymph nodes are not palpable or

tender. Trachea is midline.

Thorax is oval in shape with no tenderness or lumps present. AP to transverse is a 1:2

ratio. Chest expansion is equal bilaterally with a respiratory rate of 14 breaths per minute.

Breathing pattern is eupnic and not labored. No adventitious breath sounds audible (anterior or

posterior). Reports of dry, hacking cough noted. No secretions present during cough.

Assessment of heart/vascular/breast/lymphatic reveals an apical pulse of 78 beats per

minute. S1 and S2 sounds are audible with no thrills or heaves noted. Carotids are palpable, but

weak bilaterally. Edema present on lower extremities with 3 plus pitting. Brachial and radial

pulses strong plus 2 bilaterally. Femoral, popliteal, dorsalis pedis and posterior tibial present but


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not palpable (audible with use of doppler). Breasts symmetrical bilaterally with no lumps or

lesions present. Axillary lymph nodes not enlarged upon palpation.

Musculoskeletal assessment reveals slouched (slight) posture. No tremors present at any

time. Upper extremities equal bilaterally in strength and range of motion. Left lower hip range of

motion is limited (due to past hip injury). Strength in left and right lower legs is equal bilaterally.

Steady gait with use of a walker, may need assistance with pivoting at times. No crepitus or joint

tenderness noted on upper or lower extremities.

Neurologic assessment noted throughout. Oriented at all times upon examination, able to

recall recent and past events such as marriages and jobs from up to 40 years prior. Alert and

aware of surroundings and time. Sensory cranial nerves intact. Responds to sharp and dull

sensation test on upper and lower extremities.

E.N. is able to complete genital and peritoneal care without assistance. Assessed while

toileting. No redness or signs of inadequate skin integrity noted. Urine is extremely concentrated

with strong odor. Urine dark in color with no presence of cloudiness noted. No bowel movement

occurred for inspection.

head to toe assessment e.n. 208a

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