head to toe also

Neurological Assessment and Level of Consciousness

  • Levels of Consciousness (LOC):
    • Obtunded: Responds to light shaking, but can be confused and is slow to respond.
    • Stuporous: A painful stimulus (such as pinching a tendon or rubbing the sternum) is needed to obtain a brief response. The client may not be able to verbally respond.
    • Comatose: No response to repeated painful stimuli. Abnormal posturing is present.
  • Level of Orientation: Evaluated across four specific domains:
    • Person: Client's name.
    • Place: Where the client is located.
    • Time: Current date, month, and year.
    • Situation: The context or reason why the client is being evaluated.

Head, Face, Sensory Organs, and Neck Assessment

  • Face and Skull: Inspect for symmetry of facial features and check for the presence of edema or lesions.
  • Hair: Assess texture, distribution, and cleanliness.
  • Eyes:
    • Inspect the color of the sclera (the white of the eye), lens clarity, and the presence of any drainage.
    • Pupil Size: Normal pupil diameter is 3–7 mm3\text{--}7\,\text{mm}.
    • PERRLA: Pupils Equal, Round, React to Light, and Accommodate.
    • Pupillary Assessment Procedure:
    • Shine a penlight into the eyes starting from the periphery.
    • Note pupil size.
    • Bring the penlight inward toward the bridge of the nose when close; pupils should constrict as they accommodate to the close object.
  • Nose: Assess patency, condition of the nasal mucosa (pink, moist, and intact), and the presence of drainage.
  • Ears: Assess for pain, presence of lesions, or drainage.
  • Mouth: Inspect the condition of the lips, tongue, and inner cheeks (pink, moist, and intact), and evaluate the appearance of the teeth and gums.
  • Neck:
    • Inspect for any edema or masses.
    • Note any neck vein distention.
    • Speech Quality: Clear and articulate.
    • Swallowing: Assess for any difficulty swallowing.

Integumentary System Assessment

  • Nails: Inspect color (pink-brown), texture (smooth), thickness, and curvature.
  • Hair: Note presence and distribution of hair on the skin.
  • Skin Intactness: Inspect for presence of lesions, ulcers, pressure injuries, or surgical incisions.
  • Bony Prominences & Mobility Considerations:
    • Assess all bony prominences.
    • For clients with decreased mobility, assess the buttocks and sacral region by having the client turn over at the end of the assessment or assessing when bringing the client to the restroom.
  • Skin Properties: Evaluate skin texture, skin moisture, skin temperature, and skin cleanliness (evaluating both look and smell).
  • Skin Turgor:
    • Assessed by pinching and releasing a fold of skin.
    • Tenting: A delay in turgor response indicates poor turgor.
    • Clinical Significance: Poor turgor indicates dehydration.
    • Assessment Locations:
    • Adult: Forearm.
    • Infant: Abdomen.
  • Edema Assessment:
    • Definition: Accumulation of fluid in the tissues, appearing shiny and tight.
    • Etiology: Caused by poor venous return or trauma.
    • Nonpitting Edema: Normal.
    • Pitting Edema Grading Scale:
    • 0+0+: No pitting edema (0 mm0\,\text{mm} depression).
    • 1+1+: Trace or mild pitting edema; 2 mm2\,\text{mm} depression with rapid skin response (disappears rapidly).
    • 2+2+: Mild or moderate pitting edema; 4 mm4\,\text{mm} depression with a 10–15 second10\text{--}15\,\text{second} skin response (disappears in 10–15 seconds10\text{--}15\,\text{seconds}).
    • 3+3+: Moderate or moderately severe pitting edema; 6 mm6\,\text{mm} depression with a prolonged skin response (may last more than 1 minute1\,\text{minute}).
    • 4+4+: Severe pitting edema; 8 mm8\,\text{mm} depression with a prolonged skin response (can last more than 2 minutes2\,\text{minutes}).
    • Clinical Example: Bilateral lower extremity (bilat LE\text{bilat LE}) pitting edema.
  • Color Changes of Skin and Mucous Membranes:
    • Pallor: Loss of color. Indications: anemia, poor blood flow (lack of blood flow).
    • Cyanosis: Blue/gray color. Indications: hypoxia, impaired venous return.
    • Jaundice: Yellow/orange color. Indications: liver dysfunction, RBC destruction. Key assessment areas: sclera, posterior hand.
    • Erythema: Redness. Indications: inflammation, vasodilation, fever, rash, substance use, sun exposure.

Cardiovascular System and Peripheral Pulse Sites

  • Pulse Quality and Strength Grading Scale:
    • Pulse quality is affected by: Volume of blood in the arteries, strength of heart contractions, and elasticity of blood vessels.
    • Grading Scale:
    • 00: Absent, unable to palpate.
    • 1+1+: Diminished, weaker than expected.
    • 2+2+: Brisk, expected.
    • 3+3+: Increased, strong.
    • 4+4+: Full volume, bounding.
  • Anatomical Pulse Sites:
    • Temporal (temporal artery)
    • Facial (facial artery)
    • Carotid (carotid artery)
    • Brachial (brachial artery)
    • Radial (radial artery)
    • Ulnar
    • Apical
    • Femoral (femoral artery)
    • Popliteal (popliteal artery)
    • Posterior tibial (posterior tibial artery)
    • Dorsalis pedis (dorsalis pedis artery)

Assessment of Upper Extremities

  • CMS Assessment Framework: Focuses on Circulation, Motion, and Sensation (CMS).
  • Circulation & Vascularity:
    • Check bilateral radial pulses.
    • Check capillary refill.
    • Assess temperature and color of skin.
  • Motion & Motor Strength:
    • Assess hand grasp strength and note any weakness.
    • Range-of-Motion (ROM): Bring upper extremities through full ROM.
  • Sensory Perception:
    • Ask client to close eyes and describe location of light touch.

Assessment of Chest and Cardiac Function

  • Apical Heart Rate: Assess apical heart rate by auscultating for one full minute.
  • Normal Heart Sounds: Composed of S1S_1 (lub) and S2S_2 (dub).
  • Pulse Evaluation: Assess rate and rhythm of pulse.