Head-to-Toe Assessment Techniques in Nursing

Inspection

Visual examination of head and face characteristics.

Symmetry

Balanced proportions of facial features at rest.

Periorbital edema

Swelling around the eyes indicating potential issues.

Pupillary response

Reaction of pupils to light and accommodation.

Nasal mucosa

Inner lining of the nose assessed for color.

Oral cavity

Mouth area including mucosa, tongue, and palate.

Dentition

Condition of teeth including missing or loose teeth.

Temporomandibular joint

Joint connecting jaw to skull, assessed for pain.

Palpation

Using hands to examine body parts for abnormalities.

Nasal patency

Openness of nasal passages assessed by inhalation.

Hearing deficit

Inability to hear clearly, indicated by client behavior.

Carotid arteries

Major arteries in neck supplying blood to the brain.

Muscle strength

Ability to exert force against resistance during movement.

Trachea

Windpipe, assessed for midline position and function.

Edema

Swelling due to fluid accumulation in tissues.

Eyelids

Skin folds covering the eyes, assessed for symmetry.

Conjunctiva

Mucous membrane covering the eye, checked for color.

Iris

Colored part of the eye, assessed for shape.

External ear

Outer part of the ear, checked for drainage.

Sinus areas

Regions around the nasal cavity, palpated for tenderness.

Drainage

Fluid discharge from nasal passages or ears.

Skin Assessment

Evaluate color, condition, and lesions present.

Symmetry Check

Assess shoulders, arms, hands for size uniformity.

Joint Examination

Inspect shoulder, elbow, wrist, fingers for edema.

Nail Condition

Examine fingernails for health and abnormalities.

Palpation

Feel upper arms to hands for temperature, texture.

Pulse Assessment

Check brachial and radial pulses for rhythm.

Capillary Refill

Evaluate blood flow by pressing nail beds.

Range of Motion (ROM)

Observe joint movement in shoulders, elbows, wrists.

Muscle Strength

Compare upper and lower arm strength bilaterally.

Chest Inspection

Note posture, breathing pattern, and chest shape.

Costal Margin

Measure rib cage angle, should be 90° or less.

PMI Location

Identify point of maximal impulse at 5th intercostal.

Skin Turgor

Assess skin elasticity below the clavicles.

Breast Examination

Check symmetry, color, and condition of breast tissue.

Nipple Inspection

Look for rashes, discharge, or retraction.

Axillary Assessment

Inspect for lumps, rashes, pigmentation changes.

Heart Auscultation

Listen at four points for heart sounds and murmurs.

Breath Sounds

Auscultate anterior chest during inspiration and expiration.

Posterior Chest Assessment

Inspect shape, symmetry, and rib cage motion.

Spinal Alignment

Check client's spine for proper alignment.

Accessory Muscle Use

Note any additional muscles used during breathing.

Abdominal Assessment

Auscultate before palpation to avoid altering sounds.

Drape

Covering used to maintain client privacy during assessment.

Inspection

Visual examination of body parts for abnormalities.

Auscultation

Listening to internal body sounds using a stethoscope.

Palpation

Using hands to examine body for tenderness or abnormalities.

RLQ

Right lower quadrant of the abdomen.

Bowel Sounds

Audible noises produced by the intestines during digestion.

Peristalsis

Wave-like muscle contractions moving food through the digestive tract.

Umbilicus

Navel area, inspected for protrusion or discoloration.

Lower Extremities

Refers to the legs and feet during assessment.

Venous Distention

Swelling of veins due to increased pressure.

Capillary Refill

Time taken for color to return after pressure is applied.

ROM

Range of Motion; movement capability of joints.

Muscle Strength

Ability of muscles to exert force against resistance.

General Survey

Initial assessment of overall client appearance and condition.

Clinical Judgement

Using knowledge to tailor assessments to client needs.

Documentation

Recording assessment findings in medical records.

Objective Data

Factual information gathered during physical assessment.

Subjective Data

Client-reported information, often in quotation marks.

Health Assessment

Comprehensive evaluation of a client's health status.

Assessment Techniques

Methods include inspection, palpation, and auscultation.

Practice Repetition

Repeatedly performing skills to enhance proficiency.

Unexpected Findings

Abnormal results that require further investigation or action.