Scribd Logo
Upload

Welcome to Scribd!

  • 41 views

    Head To Toe Physical Examination PDF

    Uploaded by

    Coasfan Cossy
    The document provides guidance on performing a comprehensive head-to-toe assessment of a patient that includes 10 sections: 1) general appearance, 2) skin/hair/nails, 3) head and neck, 4) chest, 5) abdomen, 6) extremities, 7) back, 8) tubes/drains/dressings/IVs, 9) mobility, and 10) documentation. The assessment involves inspection, palpation, percussion, and auscultation of each body system and any unusual findings should be followed up with focused assessments. Proper documentation of the head-to-toe findings is important for patient safety and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Head To Toe Physical Examination PDF

    Uploaded by

    Coasfan Cossy
    41 views24 pages
    The document provides guidance on performing a comprehensive head-to-toe assessment of a patient that includes 10 sections: 1) general appearance, 2) skin/hair/nails, 3) head and neck, 4) chest, 5) abdomen, 6) extremities, 7) back, 8) tubes/drains/dressings/IVs, 9) mobility, and 10) documentation. The assessment involves inspection, palpation, percussion, and auscultation of each body system and any unusual findings should be followed up with focused assessments. Proper documentation of the head-to-toe findings is important for patient safety and care.

    Original Description:

    Original Title

    Head to Toe Physical Examination PDF

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document provides guidance on performing a comprehensive head-to-toe assessment of a patient that includes 10 sections: 1) general appearance, 2) skin/hair/nails, 3) head and neck, 4) chest, 5) abdomen, 6) extremities, 7) back, 8) tubes/drains/dressings/IVs, 9) mobility, and 10) documentation. The assessment involves inspection, palpation, percussion, and auscultation of each body system and any unusual findings should be followed up with focused assessments. Proper documentation of the head-to-toe findings is important for patient safety and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    41 views24 pages

    Head To Toe Physical Examination PDF

    Uploaded by

    Coasfan Cossy
    The document provides guidance on performing a comprehensive head-to-toe assessment of a patient that includes 10 sections: 1) general appearance, 2) skin/hair/nails, 3) head and neck, 4) chest, 5) abdomen, 6) extremities, 7) back, 8) tubes/drains/dressings/IVs, 9) mobility, and 10) documentation. The assessment involves inspection, palpation, percussion, and auscultation of each body system and any unusual findings should be followed up with focused assessments. Proper documentation of the head-to-toe findings is important for patient safety and care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 24

    Comprehensive head-to-toe assessment

    • Admission
    • At the beginning of each shift
    • Alteration in patient hemodynamic status
    • The head-to-toe assessment includes all the body systems, and
    the findings will inform the health care professional on the
    patient’s overall condition.
    • Any unusual findings should be followed up with a focused
    assessment specific to the affected body system.
    • physical examination involves collecting objective data using the
    techniques of inspection, palpation, percussion, and auscultation
    as appropriate (Wilson & Giddens,2013)
    Safety considerations
    • Perform hand hygiene.
    • Check room for contact precautions.
    • Introduce yourself to patient
    • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
    • Explain process to patient.
    • Be organized and systematic in assessment.
    • Use appropriate listening and questioning skills.
    • Listen and attend to patient cues.
    • Ensure patient’s privacy and dignity.
    • Assess ABCCS (airway, breathing, circulation, consciousness,
    safety)/suction/oxygen/safety.
    • Apply principles of asepsis and safety.
    • Check vital signs.
    • Check BMI=kg/m2
    • Complete necessary focused assessment
    1. General appearance
    Assess general appearance
    • Affect/behavior/anxiety
    • Check for conscious
    level Alterations in general appearance may reflect
    • Level of hygiene neurologic impairment, oral
    • Body position injury or impairment, improperly fitting
    dentures,
    • Patient mobility differences in dialect or language, or potential
    • Speech pattern and mental
    articulation illness.
    Unusual findings should be followed up with
    • Assess patient pain a focused neurological system assessment
    Scale from 0 to 10
    2. Skin, hair, and nails
    • Inspect for lesions, bruising, and
    rashes.
    • Palpate skin for temperature,
    moisture, and texture.
    • Inspect for pressure areas.
    • Inspect skin for edema.
    • Inspect scalp for lesions and hair
    and scalp
    for presence of lice and/or nits.
    • Inspect nails for consistency,
    colour, and capillary refill.
    • Variations in skin temperature, texture, and perspiration or
    dehydration may indicate underlying conditions.
    • Redness of the skin at pressure areas such as heels, elbows, buttocks,
    and hips.
    • Unilateral edema may indicate a local or peripheral cause bilateral-
    pitting edema usually indicates cardiac or kidney failure.
    • Check hair for the presence of lice and/or nits (eggs)
    3. Head and neck
    • Inspect eyes for drainage.(infection
    ,allergy, injury
    • Inspect eyes for pupillary reaction to
    light.
    • Inspect mouth, tongue, and teeth for
    moisture, colour, dentures
    • Inspect for facial symmetry.
    • Check pupillary reaction to light
    • Dry mucous membranes indicate decreased
    hydration.
    • Facial asymmetry may indicate neurological
    impairment
    • or injury. Unusual findings should be
    followed up with
    • a focused neurological system assessment.
    4. Chest
    •Inspect: Expansion/retraction of chest • Auscultate: For breath sounds
    wall/work of breathing and/accessory anteriorly and posteriorly.
    muscle use
    Apical heart rate
    Chest expansion asymmetrical -
    atelectasis, pneumonia, fractured ribs, Apices and bases for any
    or Pneumothorax. adventitious Sounds
    Use of accessory muscles may indicate • Palpate: For symmetrical lung
    acute airway obstruction or massive expansion
    atelectasis
    Jugular distension (Auscultate crackles or wheeze)
    Jugular distension > 3 cm above at Unusual finding -follow focused
    sternal angle. position patient at 45º respiratory assessment
    (cardiac failure)
    stethoscope
    placement for auscultation of chest
    •Auscultate apical pulse at the fifth intercostal space and
    midclavicular line
    • Note the heart rate and rhythm, identify S1 and S2, and
    follow up on any unusual findings with a focused
    cardiovascular assessment.
    5. Abdomen

    • Inspect: Abdomen for distension, asymmetry


    • Auscultate: Bowel sounds (RLQ)
    • Palpate: Four quadrants for pain and bladder/bowel distension (light
    palpation only)
    • Check urine output for frequency, colour, odor.
    • Determine frequency and type of bowel movements.
    • Unusual findings with bowel movements should be followed up with
    a focused gastrointestinal and genitourinary assessment.
    • Abdominal distension ( ascites associated heart failure, cirrhosis, and
    pancreatitis )
    •Markedly visible peristalsis with abdominal distension
    (intestinal obstruction)
    • Hyperactive bowel sounds (obstruction, gastroenteritis, or subsiding
    paralytic ileum)
    • Hypoactive or absent bowel sounds (abdominal surgery, or with
    peritonitis or paralytic ileus)
    • Pain and tenderness (underlying inflammatory conditions ,peritonitis)
    • Unusual findings in urine output ( urinary dysfunction.
    • Follow up with a focused gastrointestinal and genitourinary
    assessment
    Auscultation Palpation
    6. Extremities
    • Inspect: Arms and legs for pain, deformity, edema,pressure areas,
    bruises compare bilaterally
    • Palpate: Radial pulses, Pedal pulses: dorsalis pedis and posterior tibial
    • CWMS and capillary refill (hands and feet)
    • Assess handgrip strength and equality.
    •Assess dorsiflex and plantarflex feet against resistance
    (note strength and equality).
    • Check skin integrity and pressure areas
    • Limitation in ROM ( articular disease or injury)
    • Palpate pulses for symmetry in rate and rhythm.
    • Asymmetry may indicate cardiovascular conditions or post-surgical
    complications.
    • Unequal handgrip and/or foot strength( injury, or post-surgical
    complications)
    • CWMS ( Colour, Warmth, Movement, Sensation)
    • Check for adequacy perfusion in hand ,feet
    • Check skin integrity and pressure areas, mobility ,position of limbs
    Assess plantar flexion

    Assess dorsiflexion

    Assess CWMS
    Assess CWMS
    Palpate and inspect capillary refill

    Assess bilateral hand strength


    Assess pedal pulses
    Check capillary refill
    CRT not more than 3 sec
    • CRT indicate decreased peripheral
    circulation (cardiovascular/respiratory )
    • Clubbing of nails, in which the nails
    present as straightened out to 180
    degrees, with the nail base feeling
    spongy (heart disease, emphysema,
    chronic bronchitis)
    • Unusual findings should be followed up
    with a focused cardiovascular assessment
    7.Assess back of the patient
    • Turn patient to side or ask to sit up or lean forward
    • Inspect back and spine
    • Inspect coccyx/buttocks
    • Check for curvature or abnormalities in the spine
    • Check skin integrity and pressure areas
    • Ensure follow-up and in-depth assessment of patient mobility
    and need for regular changes in position
    8.Tubes,drains,dressings,IVs
    • Inspect for drainage, position, and function
    • Assess wounds for unusual drainage.
    • Note amount, colour, and consistency of drainage (e.g., Foley
    catheter), or if infusing as prescribed (e.g., intravenous, Urinary
    catheter bag )
    • Assess wounds for large amounts of drainage or for purulent
    drainage, and provide wound care as indicated,
    9. Mobility
    • Check if full or partial weight-bearing
    • Determine gait/balance.
    • Determine need for and use of assistive devices.
    • Assess patient’s risk for falls
    • Document and follow up any indication of falls risk
    • Note use of mobility aids and ensure they are available to the patient
    on ambulation.
    10.Report and document

    • Accurate and timely


    documentation and
    reporting promote patient
    safety

    You might also like