Head-To-ToeAssessment

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Head-To-Toe AssessmentAfter 3 hours of classroom Discussion and Demonstration the Level I students will be able to:

I. Define the FF. terms:a. Nursing Assessmentb. Physical Assessmentc. Anthropometric Measurementd. Health Historye. Healthf. Reflexesg. Visual Activityh. Interviewi. Signsj. Symptoms

II.a. Importance of Physical Assessmentb. Purpose of Physical Assessmentc. Four basic techniques in Physical Assessmentd. Principles involved in Physical Assessmente. Nursing responsibilities before, during and after

Physical Assessmentf. Materials and Equipment used in Physical Assessment

III.Demonstrate Beginning Skills in Physical Assessment.

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Head to Toe AssessmentDefine the Following terms:

A. Nursing Assessment- Is a major component of nursing care.- Is a process which includes both physical and

psychological aspect to evaluate client’s condition.- Enables the nurse to make a judgment about the

client’s health status , ability to manage his/her health care and need for nursing.

B. Physical Assessment- Is a process by which a nurse obtains a data that

describes a person’s responses to actual or potential health problems shich is analyzed to form pertinent diagnosis.

- Is a head to toe review of each body system that offers objective information about the client and allows the nurse to make clinical judgment.

C. Anthropometric Measurement- Comparative measurements of the body.

Anthropometric measurements are used in nutritional assessments. Those that are used to assess growth and

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development in infants, children, and adolescents include length, height, weight, weight-for-length, and head circumference (length is used in infants and toddlers, rather than height, because they are unable to stand). Individual measurements are usually compared to reference standards on a growth chart. Measurement of size weight and proportion of the body.

- Most commonly used anthropometric measured are height, weight, triceps, skinfold thickness, elbow breadth and arm and head circumference.

D. Health- State of being physically fit, mentally stable and

socially comfortable.- It encompasses more than the state of being free of

disease.E. Health History

- defined as the systematic collection of subjective data (stated by the client) and objective data (observed by the nurse) used to determine a client’s functional health pattern status.

F. Reflexes- Bent, turned or directed back; or produced by a reflex

without intervention of consciousness.- Is an involuntary and nearly instantaneous movement

in response to a stimulus.G. Visual Acuity

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- The degree of detail the eye can discern an image.- Is a quantitative measure of the ability to identify black

symbols on a white background at a standardized distance as the size of the symbols is varied.

- Is acuteness or clearness of vision, especially form vision, which is dependent on the sharpness of the retinal focus within the eye and the sensitivity of the interpretative faculty of the brain.

H. Interview- An interview is a conversation between two or more

people (the interviewer and the interviewee) where questions are asked by the interviewer to obtain information from the interviewee. "Interview" word is derived from french word "entirevior" it means "glimpse" to each other.

- Therapeutic interaction that has a purpose.I. Signs

- A sign is the physical manifestation of an illness, injury or other bodily disorder. A sign is objective and can be observed

- Signs can be felt, heard, seen, and measured by the diagnostician or

nurse. These include pulse, respirations, blood pressure, and physical

evidence such as bleeding, broken skin, bruising etc.

J. Symptoms

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- Subjective evidence of a disease of physical disturbance observed by the patient.

- Is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and not measured.

Importance of Physical Assessment: To early detect and treat diseases and disorders. To identify actual and potential health problems. To establish a data based from which the subsequent phases

of the nursing evolve. To assess the client’s impact of activity and exercise on the

client’s overall level of health. To assess the client’s routine exercise pattern and observe

how the client’s body system response to activity and exercise.

To establish the client-nurse relationship To obtain information about the client’s health including,

physiologic, psychologic, sociocultural, cognitive, developmental and spiritual aspects.

To identify the client’s strength and weaknesses.

Purpose of Physical Assessment To supplement, confirm or refute data obtained in the

nursing history.

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To confirm and identify nursing diagnosis. To make clinical judgments about a client’s changing health

status and management. To evaluate the physiological outcome of care. To obtain and gather data about the client’s health basis of

data for future assessment. An excellent way to evaluate an individual’s current health

status.

Four Basic Techniques in Physical AssessmentI. Inspection

It is the use of ones senses of vision and smell to consciously observe the patient. It is also known as concentrated watching. It is a close, careful scrutiny; first of the individual as a whole and then of each body system. Inspection begins the moment you first meet the individual and develop a “general survey”. Then as you proceed through the examination, start the assessment of each body system with inspection.

II. PalpationIt is the act of touching a patient in a therapeutic

manner to elicit specific information. It follows and often confirms points you noted during inspection. Palpation applies your sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or

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pulsation, rigidity or spasticity, crepitation, presence of lumps or masses and presence of tenderness or pain.

Two distinct types of palpation: Light and deep palpation Light palpation

It is superficial, delicate and gentle. In light palpation, the finger pads are used to gain information of the patient’s skin surface to a depth of approximately ½ - 1 inch below the surface. Light palpation reveals information on skin texture and moisture; overt large or superficial masses; and fluid, muscle guarding and superficial tenderness.

Deep palpationIt can reveal information about the position of organs

and masses, as well as their size, shape, mobility, consistency, and areas of discomfort. Deep palpation uses the hands to explore the body’s internal structure to a depth of 1 to 2 inches or more. This technique is most often used for the abdominal and male and female reproductive assessments. Variations in this technique are single handed and bimanual palpations.

III. PercussionIt is the technique of striking or tapping the person’s

skin with short, sharp strokes to assess underlying structures. The strokes yield a palpable vibration and a characteristic sound that depicts the location, size and density of the underlying organ. These sounds also are diagnostic of normal and abnormal findings. Any part of the body can be percussed, but only limited

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information can be obtained in specific areas such as heart. The thorax and abdomen are the most frequently percussed location.Four types of percussion techniques: Immediate or direct, mediate or indirect, direct fist and indirect fist percussion

A. Immediate or Direct PercussionThe striking hand directly contacts the body wall. This produces a sound and is used in percussing the infant’s thorax or the adult’s sinus areas.

B. Mediate or Indirect PercussionIt is used more often and involves both hands. The striking

hand contacts the stationary hand fixed on the person’s skin. This yields a sound and a subtle vibration.

C. Direct Fist PercussionIt is used to assess the presence of tenderness in internal

organs, such as the liver or the kidneys. The presence of pain in conjunction with direct fist percussion indicated inflammation of that organ or a strike of too high in intensity.

D. Indirect Fist PercussionIts purpose is the same as direct fist percussion. In fact, the

indirect method is preferred over the direct method. It is because in this methods. The non dominant hand absorbs some of the force of the striking hand. The resulting intensity should be sufficient force to produce pain in the patient if organ inflammation is presentPercussion elicits five types of sounds:

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1) Flatness (dull) – bone and muscle2) Dullness (thudlike) – liver, spleen, heart3) Resonance (hollow) – air-filled lung/ normal lung4) Hyperresonance – emphysematous lung5) Tympany – stomach filled with gas (air)

IV. AuscultationIt is the act of active listening to the body organs to gather information on patient’s clinical status. Auscultation includes listening to sounds that are voluntarily and involuntarily produced by the body such as the heart and blood vessels and the lungs and abdomen. Auscultated sounds should be analyzed in relation to their relative intensity, pitch, duration, quality, and location.

Two types of auscultation: Indirect and direct auscultation:1) Direct of Immediate auscultation

It is the process of listening with the unaided ear. This can include listening to the patient from some distance away or placing the ear directly on the patient’s skin surface. And example is the wheezing that is audible to the unassisted ear in a person having a severe asthmatic attack.

2) Indirect or Mediate auscultationIt is the use of stethoscope, which transmits the sounds to the nurse’s ear.

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Principles involved in physical assessment:Anatomy & Physiology

One has to know the different parts and functions of the body in order to do a thorough and detailed assessment.Psychology

Through Psychology, we are able to make good assessments because we can differentiate a normal mental state and an abnormal one.

Privacy must be ensured during the Physical Assessment to avoid the client from being anxious or uncomfortable.Microbiology

Do medical handwashing before and after the procedure. Instrument should be sterile.Time and energy

Starts from lesser to the most sensitive partBody mechanics

Nurse and patient should maintain proper body mechanics.

Nursing responsibilities before, during and after Physical assessment

Before Always dress in clean professional manner, make sure you

have your name pin or workplace identification. Remove al bracelets, necklaces, or earrings that can

interfere during the physical assessment.

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Be sure your hair will not fall forward and obstruct your vision or touch to the patient.

Ensure that all necessary equipment is ready for use and within reach.

Introduce yourself to the patient. Enlist the patient’s cooperation by explaining what you are about to do, where it will be done, and how it may feel.

Explain to the patient why you may be spending a long time performing one particular skill.

Do medical hand washing Position the patient as dictated by the body system being

assessed. Warm all instruments prior to their use

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Conduct the assessment in a systematic fashion every time. While performing each step in the physical assessment

process you may need to inform the patient of what to expect, where to expect it, and how it should feel.

Avoid making crude or negative remarks, be cognizant of your facial expression when dealing with malodorous and dirty patients or with disturbing findings.

Proceed from the least invasive to the most invasive procedure for each body system.

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If the patient complains of fatigue, continue the assessment later.

After Provide recognition to the patient when the physical

assessment concluded; inform the patient what will happen next.

Place patient in a comfortable position. Do after care. Do medical hand washing. Document assessment findings in the appropriate section of

the patient record.

Materials and Instruments of Physical Treatment

Supplies PurposeFlashlight or penlight

To assist in viewing of the pharynx and cervix or to determine the reaction of the pupils of the eye.

Laryngeal or dental mirror

To observe the pharynx and oral cavity.

Nasal septum To permit visualization of the lover and middle turbinates; usually a penlight is used for illumination.

Ophthalmoscope A lighted instrument to visualize the interior of the eye.

Otoscope A lighted instrument to visualize the

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eardrum and external auditory canal (a nasal speculum may be attached to the Otoscope to inspect nasal cavities).

Percussion (reflex) hammer

An instrument with a rubber head to test reflexes.

Tuning Fork A two-prolonged metal instrument used to test hearing acuity and vibratory sense.

Cotton applicators To obtain specimens.Gloves To protect the nurseLubricant To ease the insertion of instruments

(ex.Vaginal Speculum)Tongue blades (depressors)

To depress the tongue during assessment of the mouth and pharynx.

Various positioning of the patient

Dorsal recumbentBack-lying position with knees flexed and hips externally

rotated; small pillow under the head; soles of feet on the surface.Supine (horizontal recumbent)

Back-lying position with legs extended; with or without pillow under the headSitting

A seated position. The back is unsupported and legs hanging freely.

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LithotomyBack-lying position with feet supported in stirrups; the hips

should be in line with the edge of the table.Sims

Side-lying position with the lowermost leg flexed at the hip and knee, upper arm flexed at the shoulder and elbow.Prone

Lies on the abdomen with head turned to the side, with or without a small pillow.

Body Parts

Assessment of Body PartsHead & NeckHeadInspection:For size, shape & symmetry

Palpation:For contour, masses, depressions.

HairInspection:For color, evenness of growth over the scalp, presence of parasites, amount of body hair.

Palpation:Thickness or thinness texture and oiliness.

Scalp

Normal Findings

The head should be round (normocephalic) and symmetrical.

The normal skull is smooth, and without masses or depressions, non tender.

Can be black, brown or burgundy depending on the race, evenly distributed covers the whole scalp (no evidences of Alopecia), no parasites, and the amount is variable.

Maybe thick or thin, coarse or smooth neither brittle nor dry.

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Inspection:For Color, oiliness, presence of scars, lice and dandruff.

Palpation:For lesions or masses tenderness.

ForeheadInspection:For symmetry, skin appearance, presence of rushes, scars or pimples.

Palpation:For masses, lumps and tenderness

FaceInspection:For shape and symmetry, presence of scars, pimples or acne

Palpation:For any swelling, masses, lumps, and the four sinuses (sphenoidal sinuses, frontal sinuses, ethmoid sinuses and maxillary sinuses).

EyesInspection:For symmetry.

EyebrowsInspection:For hair distribution and alignment and skin quality and movement, presence of pimples, dandruff and color of the hair.

Lighter in color than the complexion, can be moist or oily, no scars noted, free from lice, nits and dandruff.

NO lesions should be noted, neither tenderness nor masses.

Symmetrical, light to dark brown, no rushes, scars and pimples.

Non-tender, no lumps and absence of masses.

The shape of the face can be oval, round, or slightly square, the face is symmetrical, absence of scars, pimples or acne. There should be no edema, disproportionate structures, or involuntary movements.

No lumps and swelling of the face, absence of masses and there is no pain felt during palpation of face

Symmetrical or evenly placed and inline with each other. Non protruding and equal palpebral fissure.

Hair evenly distributed; skin intact. Eyebrows symmetrically aligned; equal movement, absence of pimples and dandruff,

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Palpation:For the presence of lumps, pain and nodules.

EyelashesInspection:For evenness of distribution and direction of curl and color

ScleraInspection:For color, moisture, texture and the presence of lesions.

ConjunctivaeInspection:For lesions, swelling, color and moisture.

Palpation:Presence of pain

CorneaInspection:For clarity, texture and moisture

IrisInspection:For appearance, coloration and shape.

PupilInspection:For color size, shape and equality of the pupils

maybe black brown or blond depending on race.

No lumps, no nodules and no pain felt during palpation

Equally distributed; curled sightly outward and black in color.

The sclera appears white, although blacks occasionally have a gray-blue or “muddy” color to sclera. It should be moist and without lesions

Both conjunctivae are shiny, smooth, and pink or red, absence of swelling, no lesions and it should be moist.

There should be no pain felt during palpation.

The corneal surface should be moist, shiny and transparent, with no discharges and cloudiness.

The iris is normally appears flat, with a regular shape and even coloration.

Black in color; appears round, regular, smooth border and of equal size in both eyes, normally

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Muscle functionCorneal Light Reflex or the Hirschberg Test(Observe the location of reflected light on the cornea)

Cover TestThis test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps two eyes parallel. (Observe the cover eye for movement)

Diagnostic Position testLeading the eye through the six cardinal positions of gaze will elicit any muscle weakness during movement. (Observe for convergence of gaze).

Muscle balanceTest for pupilary light reflex(Cardinal Fields of Gaze)

Test for Accommodation

3-7 mm in diameter.

The reflected light (light reflexes) should be seen symmetrically in the centers of the cornea.

If the eyes are in alignment, there will be no movement of the either eye.

A normal response is parallel tracking of the object with both eyes. Both eyes should move smoothly and symmetrically in each of the six fields gaze and convergence on the held object as it moves toward the nose.

Normally you will see:-Constriction of the same-sided pupil (a direct light reflex).-Simultaneously (a consensual light reflex).

A normal response includes:-Papillary constriction.-Convergence of the axes of the eye.Record the normal response to all these maneuver as:P - PupilsE - EqualR - RoundR - React toL - Light andA - Accommodation

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Visual AcuitySnellen eye ChartThe Snellen eye chart is the most commonly used and accurate measure of visual acuity.

Peripheral VisionTest Visual FieldsConfrontation Test

NoseExternal Inspection:Inspect the nose nothing any bleeding, inflammation, or lesions, masses, swelling, and symmetry, discharges and color, sense of smell.

External Palpation:For tenderness and presence of pain.

Internal Inspection:Inspect for nasal septum for deviation, perforation, lesions and bleeding.

Frontal SinusesInspection:

Normal Visual is 20/20The Top number (numerator) indicates the distance the person is standing from the chart, while the denominator gives the distance at which a normal eye could have read that particular line. Thus 20/20 means you can read that 20 ft. with the normal eye could have read at 20 ft.

The patient is able to see the stimulus at about 90 degrees temporally, 60 degrees nasally, 50 degrees superiorly, and 70 degrees inferiorly.

The shape of the external nose can vary greatly among individual. Normally, it is located symmetrically on the midline of the face that is without swelling, bleeding, lesions, or masses. No discharge or flaring and uniform color, there is a sense of smell.

Non-tender; absence of pain

The nasal mucosa should be pink or dull red without swelling. The septum is at the midline and without perforation, lesions or bleeding, the small amount of watery discharge is normal.

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For any swelling around the eyes

Palpation:Presence of pain and tenderness

Percussion:Note any sound

Maxillary SinusesInspection:For any swelling around the eyesPalpation:Presence of pain and tenderness

Percussion:Note any sound

Transillumination of the sinusesYou may use this technique in the frontal and maxillary sinuses when you suspect sinus inflammation, although it is of limited usefulness.

MouthLipsInspection:For color, texture, cracking, symmetry, lesions and hydration

Palpation:For any presence of pain, lumps and tenderness.

GumsInspection:For color, texture, swelling, bleeding, retraction form the teeth

Palpation:

There is no evidence of swelling around the eyes.

The patient should not feel pain during palpation and no tenderness felt.

The sound should be flat or dull.

There is no evidence of swelling around the nose and eyes.The patient should not feel any pain and tenderness during palpation.

The sound should be flat or dull.

The glow on each side is equal, indication air-filled frontal and maxillary sinuses.

The lips should be pink, soft moist, smooth texture with no evidence of lesions or inflammation. Not crack and symmetrical.

There is no presence of lumps and pain. It is tender.

The gums should be pink, moist, firm texture, no retraction, no swelling or bleeding. The gum margins at the teeth are tight and well-defined.

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For the presence of pain, tenderness and lumps.

TeethInspection:For discoloration, numbers of tooth and texture.

TongueInspection:For color, texture, surface characteristics, symmetry, presence of lesions, and sense of taste.

Palpation:For any nodules, lumps and presence of pain

FrenulumInspection:For the color, texture.

Sublingual AreaInspection:For color, moisture and presence of lesion.

Hard palateInspection:For color, shape, texture, presence of lesions and malformation.

Soft PalateInspection:

There should be no pain felt during palpation, no lumps and non-tender.

The adult normally has 32 teeth, which should be white, straight and smooth edges in proper alignment or evenly placed, clean and free of debris or decay.

The tongue is in the midline of the mouth, the dorsal surface should be pink, moist, rough and without lesions. The tongue is symmetrical and moves freely. The strength of the tongue is symmetrical and strong.The ventral surface of the tongue ahs prominent blood vessels and should be moist without lesions, looks smooth and glistening. There is a sense of taste.

There should be no presence of nodules, lumps and pain.

It should be attached to the tongue, pinkish in color and moist.

It should be pink in color, moist and no presence of lesions.

The hard palate is concave and lighter in pink in color, it has many ridges and it is moist, without any lesion or malformation.

The soft palate is also concave

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For color, shape, texture, presence of lesions, malformation

UvulaInspection: For position, mobility and color.

TonsilsInspection: For color, shape, size and discharge.

Palpation:Presence of pain

EarsExternal earInspection: For position, color, size, shape, any deformities, inflammation, or lesions

Palpation: Presence of pain, tenderness, and lumps.

Auditory AcuityVoice-Whisper test

and light pink in color, it is smooth and no lesions or malformations noted.

It normally looks like a flesh pendant hanging in the midline of soft palate. Tonsils are present and pink in color.

It is pink in color and smooth. Oval in shape. No discharge. Of normal size or not visible, no inflammation, and not swollen.

There should be no pain felt during palpation.

The ear matches the flesh color of the rest of the patient’s skin and should be positioned centrally and in proportion to the head. The top of the ear should cross an imaginary line drawn from the outer canthus of the eye to the occiput with no swelling or thickening. Cerumen should be moist and not obscure the lympanic membrane. There should be no foreign bodies, redness, drainage, deformities, nodules or lesions.

They should feel firm (not tender) and movement produce pain.

The patient should be able to repeat words whispered from a

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Tuning fork test

Weber’s Test

Rinne’s Test

NeckInspection: For symmetry of the sternocleidomastoid muscles anteriorly, and the trapezius posteriorly.

Palpation: For the presence of masses and tenderness.

Lymph NodesInspection: For any enlargement or inflammation.

Palpation:For size, shape, dellimination,

distance of 2 feet.

Measures hearing by air conduction (AC) or by bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear.

The patient should perceive the sound equally in both ears or “in the middle”. No lateralization of sound is known as negative Webster test. Air conduction is heard twice as long a bone conduction when the patient hears the sound through the external auditory canal ( air ) after it is no longer heard at the mastoid process ( bone ). This is denoted as AC>BC.

The muscles of the neck are symmetrical with the head at a central position. The patient is able to move head through a full range of motion without complaint of discomfort or noticeable limitation. The patient may be breathing through a stoma or tracheostomy.

The muscles are symmetrical without palpable masses or spasm.

Lymph nodes should not be visible or inflamed.

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mobility, consistency, and tenderness

TracheaPalpation:

Thyroid GlandInspection:For symmetry and visible masses.

Palpation:For nodules or enlargement and tenderness.

Normally, lymph nodes should not be palpable in the healthy adult patient; however, small, discrete, movable nodes are sometimes present but are of no significance.

Space should be systemic on both sides or on central placement in midline of neck; spaces are equal on both sides.

Thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection. In males, the thyroid cartilage, or Dm’s apple, is more prominent than in females.

No enlargement, masses, or tenderness should be noted on palpation.

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Appendices

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Equipment and supplies used for a Health Examination

Various Positioning of the Client

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Flashlight or Penlight Otoscope

Dental MirrorOpthalmoscope

Tuning ForkCotton Applicators

Tongue DepressorsGloves

Lubricant Percussion Hammer

Nasal Speculum

Dorsal RecumbentLithotomy

Basic Techniques used in Physical Assessment

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SimsHorizontal Recumbent or Supine

Sitting or High Fowlers

Prone

Direct PercussionIndirect Percussion

Deep Palpation

Parts of the Eye

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Light Palpation

Snellen Eye Chart

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Sinus’ Locations

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Side View

Front View

Structures of the Mouth

Structures of the Ear

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Lymph Nodes of the Head and Neck

External & Internal Lymphatic Drainage

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