HEAD TO TOE ASSESSMENT General Appearance [inspection] Gender, race, age Signs of distress (angry, pain, anxiety) Affect and mood Orientation x3? (person, place, time), LOC Speech pattern Body type (obese, frail, muscular) Posture, gait, movements Hygiene and grooming
Skin, hair and nails [inspect and palpate] Can by done while assessing other body parts or by itself skin should be intact, dry, smooth color congruent for race? mucous membranes should be moist and pink turgor (elasticity) should be immediate pressure areas? Nails smooth
Abdomen [inspect, auscultate, palpate, percuss] Know landmarks for each quad Active bowel sounds (every 5-35 sec.) Soft, non-tender
Abnormals:
Head [inspect and palpate] Should be upright and still Abnormals: Symmetrical facial features Eyes – sclera white, pupil clear, smooth equal movement, PERRLA, ears – symmetrical, no drainage mouth – membranes pink and moist, palate intact, no swelling in throat neck – soft, no swollen lymph nodes carotid arteries palpable dentition
Chest and lungs [inspect, auscultate, palpate] Symm Symmet etri rica call expa expans nsio ion n with with respiration Lung sounds – vesicular, broncho-vesicular,bronchial Heart sounds – S1 & S2 (lub dub) PMI – point of maximal impulse (apex) cough Ease and depth of respirations Peripheral pulses
Abnormals:
Abno Abnorm rmal als: s:
diaphoresis petechiae cyanosis edema pallor bruising jaundice erythema excessive pigmentation eczema induration ridged or broken nails
paralysis asymmetrical features lesions/sores in mouth/ears drainage/matting in eye glaucoma cataracts strabismus ny nystagmus ptosis exophthalmos congunctivitis caries varicosities
hernias distention hypo/hyperactive bowel sounds striae palpable masses pulsing masses absent bowel sounds (2-5 min.)
Vascular system [inspect, ausculate, palpate] Inspect for bounding or distended pulse arteries & edema Palpate for pulse, palpate edema Auscultate for abnormals
Abnormals:
Genitals an and re rectal ar area [i [inspect, pa palpate] voiding sufficient quantity? foley present? last BM?
Abnormals:
hemorrhoids Lesions/chancres Rectocele/cystocele
discharge
Musculoskeletal system [inspect, palpate] ROM reflexes
Abnormals:
kyphosis Scoliosis osteoporosis dec re rea se se d ROM hyper/hypotonicity
lordosis
Other:
bruit
delayed capillary refill (>3sec.) phlebitis
any tubes present (IV, foley, oxygen, etc)? Dressings? Describe type and any drainage present Incisions? Intact with staples, color of surrounding skin, etc.
CRANIAL NERVE ASSESSMENT
adve advent ntit itio ious us soun sounds ds:: crackles (rales) rhonchi wh e e z e s pleural S3 or S4 murmers thrill dysrythmia clubbed fingers
I II III IV V VI VII VII VIII VIII IX X XI XII XII
bruising absent/weak, thready
Identify familiar odors Visual Acuity Pupillary response Fo llllo w y ou ou r f in in ge ge r w /o /o mo mov in ing he he ad ad Asse Assess ss for for sha sharp rp,, dull dull sen sensat satio ions ns on on face, face, have have pat patie ient nt hol hold d mout mouth h open open Fo llllo w y ou ou r f in in ge ge r w /o /o mo mov in ing he he ad ad Have Have pat patie ient nt smi smile le,, diffe differe rent ntia iate te bet betwe ween en swe sweet et and and sou sour r Hear Hearin ing: g: snap snap fing finger erss clo close se to ears ears Balance: feet together, arms at sides with with eyes closed for 5 sec. H av ave pa pa titi en en t sw al al lo lo w a nd nd sa sa y “A hh hh” Elicit gag reflex Have pa patient sh shr ug ug sh shoulders Have Have pat patie ient nt sti stick ck out out ton tongu guee and and mov movee from from side side to to side side
atrophy
