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 clientUse light pressure first to assess body surfaceNext use deep palpation to assess underlying

structuresAssess 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 ofPercussion 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 durationHeard over solid areas (muscle)

Dullness = medium intensity, medium pitch, medium durationHeard over fluid-filled areas

Resonance = loud intensity, low pitch, long durationNormal lung sound

Hyper resonance = very loud intensity, lower pitch, longer durationHeard over hyperinflated areas (emphysema)

Tympany = loud intensity, high pitchHeard 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 systemAppearance and behavior

Appears stated ageSpeech/behavior appropriate to developmental

stageFacial expressionsPhysical/emotional distressSkin color

Vision and hearingGlasses, hearing aid, etc

General Survey (cont’d)Speech

Appropriate, logicalTone, speed, and clarityVocabulary/grammar

Body type and postureBody size/buildMobility, gait, and coordinationPhysical deformitiesRange of motion

Dress, grooming, and hygienePoor hygiene/unkemptManner of dress appropriate for climate

General Survey (cont’d)Mental status

Level of consciousnessOrientationMood, 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.

InteractionVital signs

T/P/R and BPPain assessmentAllergies

Height and weightNutritional statusUnexplained weight loss

Skin AssessmentSkin 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 VariationsColorColor

VariationVariationDescriptionDescription SignificanceSignificance

Pallor Loss of pink/yellow tones or extreme paleness in light-skinned clientsLoss of red tones in dark-skinned clients

Poor circulation, low hemoglobin levelAssess 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 disordersAssess 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-yellow) area

Bruising may indicate physical abuse

Petechiae

Tiny, pinpoint red or reddish-purple spots

Extravasation of blood into the skinMay be associated with a disorder or medication

Skin Assessment (cont’d)Skin characteristics (cont’d) --

Texture Should be smooth and soft May be affected by exposure, age, endocrine disorder,

and impaired circulationTurgor

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.

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 Pitting EdemaTrac

eMinimal 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

Assessing the HairAssess for color, texture, condition, and

distributionPediculosis = head lice infestationNits (lice eggs) may be found on the hair shaft

close to the scalpAlterations in hair distribution may be the

sign of diseaseAlopecia = hair loss

Chemotherapy Nutritional deficiencies

Hirsutism = excess facial or trunk hair Endocrine disorders Steroid use

Assess scalp (dandruff, dermatitis, psoriasis, etc)

Assessing the NailsCondition of Condition of Nail/Nail BedNail/Nail Bed

Indications or ConcernsIndications 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 SignsBody temperature

Wait for 15-30 minutes after the client smokes or eats/drinks something hot/cold before taking an oral temperature

RespirationsCount unobtrusively for 30 seconds if respirations

are regular, and for 60 seconds if they are irregular

Observe rate, rhythm, and depth of respirationsBlood pressure

Client should be seated with both feet on the floorClient should be inactive for 5 minutes before

measuringUse 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 secondsNote pulse rate, rhythm, and quality, as well

as the S1 and S2 heart sounds

Assess radial pulseMake sure client is resting while assessing the

peripheral pulsePalpate 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 HeadObserve 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 indicatedAcromegaly, 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 EyesExternal structures

PERRLA (pupils equal, round, reactive to light and accommodation)

Conjunctiva: smooth, glistening , and ‘peach’ in color

Sclera: smooth, glistening, and blue-white in colorCornea: transparent, smooth, and moist

Visual acuitySnellen chart measures distance vision

Myopia = diminished distance visionNear 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 EarsOtic 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 tragusMiddle 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 earInner ear = hearing and equilibrium

Cerumen (ear wax) should be present, but should not occlude the ear canalMay be black, dark red, gray, or brown in color

Assessing the NoseSinus areas should be nontender upon

palpationNasal passages should be pink and moist,

and free from drainage or lesionsSeptum should be symmetricalAssess client’s ability to breathe freely

through both sides of the noseSense of smell is diminished in older adults

due to atrophy of olfactory nerve fibers

Assessing the Mouth and NeckBuccal mucosa should be smooth, moist,

and pink:Common Buccal/Oral VariationsCondition of Condition of

Mouth/Oral MucosaMouth/Oral MucosaIndications or ConcernsIndications 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 symmetricalAssess for swelling or droopingAssess for difficulty swallowing

Assess teeth for dentures, obvious caries, loose teeth

Tongue should be moist, symmetrical, slightly rough, smooth, pink, and freely movableAbnormal 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, thyroidInspect for swelling, ROM

Lung AssessmentAlterations in respiratory rate

Bradypnea = slow respirations (<10 breaths/minute)Tachypnea = fast respirations (>24 breaths/minute)

Alterations in respiratory effortDyspnea = labored breathingOrthopnea = inability to breath in the horizontal

positionAbnormal 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 AssessmentObserve the precordium (area of the chest

over the heart) for pulsations or heavesAbnormal 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 chestMay indicate abnormal blood flow and/or

presence of a heart murmurAssess circulation

Palpate peripheral pulsesCheck capillary refillAssess Homan’s sign or calf tendernessAssess extremities for peripheral edema

Cardiovascular Assessment (cont’d)

Blood pressureCuff 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 smallUse 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 rhythmListen to apical pulse for full minuteCompare apical pulse to radial pulses

Assessment of the ExtremitiesAssess for musculoskeletal abnormalities, as

major deformities may affect posture and gaitKyphosis = accentuated thoracic curveScoliosis = lateral ‘S’ deviation of the spineLordosis = 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 otherMovements should be smooth and controlled

Extremity Assessment (cont’d)Joints should be smooth, nontender, warm to

the touch, and of similar color to surrounding tissueColor changes may indicate inflammation or infectionAssess 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 exercisesShould be strong and equal bilaterally

Test ‘hand grasp’ strength and ‘foot push’ strengthBoth 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 malesCircumcision = 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 ChartingTells the story of the patient’s experience

in a chronological formatGoal = 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 AbdomenInspect 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 abdomenDiscontinue NG suction (or clamp tube) if indicatedAbsent bowel sounds = no sound auscultated after

listening for 5 minutesHypoactive 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 abdomenUse light palpation (pads of fingertips) to evaluate for

tenderness and guarding, superficial masses Involuntary rigidity of the abdominal muscles may indicate

peritoneal inflammationUse 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 tympanicLiver should be dull over right MCLStomach should be tympanic at left lower anterior

ribcageSpleen should be dull near left 10th rib posterior to MAL

Objective Two

Demonstrate the assessment technique of

percussion of the thorax and abdomen

Examination of the ThoraxThorax = formed by the ribs, sternum, and

vertebrae; protects the heart, lungs, and great vesselsAssess with client in sitting positionObserve 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 downwardLight 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 assessmentShould 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 airAbnormally 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 roomSwitch on ophthalmoscope light; turn lens disc to 0Keep 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 eyeUse large round beam (0) for large pupilsUse small round beam for small pupilsUse 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 discShould be yellowish orange, oval or roundShould 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 clearLens should be transparent

Assess for the ‘red reflex’ (orange glow)Absence may indicate cataract, detached retina,

or artificial eyeKeep light beam focused on the red reflex as you

move ophthalmoscope closer to the pupilIdentify 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 discUse clear glass lens for normal-sighted clientUse 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 abnormalitiesFlame-shaped hemorrhages may indicate

hypertensionLarge, horizontal line may indicate preretinal

hemorrhageTiny 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 ExaminationEar Assessment

Perform examination in a darkened roomUse the largest speculum the ear canal can

accommodateHave the client tilt head toward the side not being

examinedPull 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 speculumObserve lower portions of the nose, then the upper

portions

Otoscopic Examination (cont’d)

Assessing the Nose (cont’d) --Use short, wide nasal speculumObserve lower portions of the nose, then the

upper portionsAssess 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/otos

cope

(*Lab Practice)