Head-to-Toe Assessment Notes

INTRODUCTION

Health assessment helps nurses understand a patient's overall physical, psychological, sociocultural, developmental (can change assessment by adjusting teaching plan or bringing it to their level), and spiritual health.

INDICATION OF HEALTH EXAMINATION

Health examinations are typically conducted:

  • On admission

  • When there's a change in patient status (Ex headache)

  • Post intervention (Ex giving Tylenol to a patient and follow up)

  • On discharge (always document and put in a health assessment when passing off patient or leaving.)

  • During follow-up appointments

  • Before and after diagnostic and therapeutic procedures

PRE-PREPARATION FOR ASSESSMENT

  • EXAMINATION ROOM: The examination room should have specific characteristics:

    • Warm environment.

    • Well-lit and comfortable.

    • Allow the patient time to settle in. (white-coat syndrome give them time to relax)

IMPORTANT ASPECTS OF PHYSICAL EXAMINATION

  • Body position of RN (Registered Nurse): The nurse's body language and positioning can:

    Don’t stand too close or too far away and raise the bed always to ensure comfort and accessibility during the assessment.

    • Reduce patient nervousness

    • Establish a good nurse-patient relationship

  • Body position of patient: Ensure the patient is in an appropriate position for the assessment. For example, a patient should be able to lay flat for an abdominal assessment.

  • Location: The room should be appropriate for the exam. (ex suicidal patients need a sitter)

POSITIONING

  • Children aged 3 months – 1 year should be allowed to sit in their mother’s lap.

  • Children aged 1 year - 3 years should be in the standard required position on the examination table.

THE FOUR PRINCIPLES OF PHYSICAL EXAMINATION

  • Inspection

  • Palpation (should be last)

  • Percussion

  • Auscultation

  • Note: Abdominal assessments have a slightly different order.

HEAD TO TOE ASSESSMENT: VITAL PARAMETERS

Vital signs should be assessed at the beginning of the general survey:

when checking BP, you can talk to the patient and get information on the patient

  • Temperature

  • Pulse

  • Respiration

  • Blood pressure

  • Capillary refill time

  • Hydration

  • Oxygen saturation

HEAD TO TOE ASSESSMENT

  • Patient assessment begins upon first contact, including:

    • Apparent state of health

    • Level of consciousness

    • Signs of distress

    • General height, weight, and build

    • Skin color, dressing, grooming, personal hygiene

    • Facial expression, gait, odour, posture

  • Introduction to the patient can also determine A/O (Alert and Oriented) status.

  • Vital signs assessment should be the first step in physical assessment because moving the patient can interfere with accurate results. Specific vital signs can also be obtained during the assessment of individual body systems.

HAIR AND SCALP

  • Hair: Assess and note: (don’t say is present)

    • Type (long, coarse, thick, brittle)

    • Color

    • Distribution

    • Quantity

    • Thickness

    • Texture

    • Lubrication

  • Scalp:

    • Inspect by separating the hair.

    • Wear clean gloves if lesions or lice are suspected.

    • Check for symmetry and skin breakdown.

NAILS

  • The condition of the nails reflects general health, nutrition, occupation, and self-care level.

  • Nail biting can reveal a person’s psychological state. could be an indication of anxiety

    nails can change for diabetic patients, age, etc

  • Inspect:

    • Nail bed color

    • Cleanliness

    • Length

    • Texture

    • Angle between nail and nail bed

    • Folds around the nail

HEAD

The assessment of the head includes:

  • Eyes

  • Ears

  • Nose

  • Mouth and pharynx

EYES

  • Assess:

    • Visual acuity

    • Position and alignment

    • Eyebrows and eyelids

    • Abnormal discharges

    • Color of conjunctiva and sclera

    • Pupil size and reaction to light (Equal/reactive to light?)

EAR

Important for trauma patients leaking spinal fluid, blood from the ears Ex car accident

  • Assess:

    • Integrity of ear structures

    • Hearing acuity

    • Sores and discharges

NOSE

Assess for:

  • Polyps

  • Redness

  • Sores

MOUTH

Inspect:

  • Lips for sores and color

  • Tongue (should be moist/pink)

  • Loose/broken teeth

  • Lesions

  • Midline uvula

  • Tonsils

NECK

The assessment of the neck includes:

  • Lymph nodes

  • Carotid artery

  • Trachea

    • Extend neck and trachea should be midline.

    • Assess for JVD (Jugular Vein Distention)

    • Carotid artery assessment should be done one side at a time.

UPPER EXTREMITIES

Assess:

  • Symmetry

  • Lesions

  • IV sites (make sure there is no redness could be sign of infection)

  • Pulses

  • Musculoskeletal abnormalities/ROM (Range of Motion)

  • Capillary refill (should be 2 to 3 seconds)

  • Skin turgor

  • Drift (if a patient can’t keep their arm pointing forward without it drifting down with their eyes closed indicates stroke)

CHEST

Assess: A P E T M

Dont be afraid to touch your patients

  • Accessory muscles/work of breathing

  • Heart/lung sounds

  • breathe in with your nose and out with mouth for best sound

ABDOMEN

check bellybutton for deformities

  • Inspect the skin for color, sores, lesions, scars, position of umbilicus, distention, and contours.

  • Always auscultate before palpation or percussion because touching can alter the assessment.

  • Palpate for tenderness, masses, and enlargement of organs like the liver, spleen, and kidney.

  • Ask about bowel and bladder elimination.

  • Percussion is used to detect the location of normally palpable organs (e.g., liver, spleen, and intestines).

  • always be sure to check foley to avoid urinary infections

  • ostomy should always be red a beefy red if not could indicate color change, which may suggest inadequate blood supply or ischemia, requiring prompt medical evaluation.

  • should hear 5-30 sound in RLQ - RUQ - LUQ- LLQ do this last if the area is tender and painful

  • when palpating be sure to feel for any lumps, masses, or any abnormalities

  • start with light then firm pressure during palpation to assess for any tenderness or discomfort.

GENITALIA

  • Ask about

  • ask if they are comfortable with the assessment if they would rather have a female etc

  • always bring a buddy when assessing genitalia to ensure both comfort and accuracy during the examination, as well as to provide support for the patient.

  • patients that have renal deficiency should be asked about urinary changes, such as frequency, urgency, and any pain experienced during urination.

    • Dysuria or urine changes

    • Abnormal discharge

    • Sores

    • Warts

    • Itching

LOWER EXTREMITIES

Assess:

  • Skin color

  • Swelling

  • Redness

  • Big toe/bottom of feet

  • Pulses (palpate)

  • Range of motion

  • older adult patients might have to have feet assessed do to diabetes having neuropathy or other circulatory issues that can affect their overall foot health.

CONCLUSION

A thorough physical examination should yield 20%20\% of the data needed for patient diagnosis and management.