Jan
08
Head to toe Nursing Assessment: A Detailed physical exam and health assessment

nursing head to toe assessment

A physical examination is a procedure that involves assessment and collection of objective data from the body systems by using the techniques of inspection, palpation, percussion and auscultation as appropriate.A head to toe assessment is the assessment of all the body systems, and the findings will inform the health care professional on the patient’s overall condition.

In nursing, it is important to carry out either a full head to toe assessment or a focus assessment, depending on the situation.

Head to toe assessment Versus Focused Assessment: What is the difference ?

A full head to toe assessment is usually useful on at the beginning of each shift, on patient admission or when a patient’s hemodynamic state is compromised.

A focus assessment like the name suggests is an assessment that focuses on a single system. It gives the health care provider more details about what is going on with a patient in that particular body system.

Any unusual findings should be followed up with a focused assessment specific to the affected body system.

In this article, I will be going into details about how to perform a nursing head to toe assessment and some abnormal findings. So Let’s get started!

Procedure checklist

  • Perform hand hygiene
  • Check room for additional precautions e.g (contact, droplet, airborne).
  • Introduce yourself to patient
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth) and check that it matches the patient’s medical health record.
  • Explain process to patient
  • Get informed consent
  • Check patient’s level of consciousness and orientation
  • Use appropriate listening and questioning skills
  • Listen and attend to patient cues
  • Ensure patient’s privacy and dignity
  • Assess ABCDEE (airway, breathing, circulation, disability, environment, equipment)/suction/oxygen/safety.
  • Apply principles of asepsis and safety
  • Check vital signs
  • Complete necessary focused assessments
  • Document results in the patient’s chart

Level of Consciousness and orientation

Begin by assess the patient’s level of consciousness, determine which category they fall into. Are they ( Alert, confused, lethargic, obtunded, stuporous or comatose).

  • Alert: This is the state when the patient is fully awake and aware of their surroundings.
  • Confused: disorientation either to time, person, place, situation or a combination of two or more of these. Also, a confused patient’s actions and speech may be inappropriate to the situation. For example, if you introduce yourself to the patient and they say “where can I get the bus to go to the supermarket, I have to get some book to read”. This statement tells you that the patient may be confused because their statement is inappropriate to the situation.
  • Lethargic: Severe drowsiness that can be caused by illness, drugs or disorders.
  • Obtunded: Reduced alertness with slow responses to stimuli. Requires continuous stimulation to maintain attention.
  • Stupor: person is minimally responsive to vigorous stimulus such as pinching nose, sternal rub, shining light in the eyes, e.t.c.
  • Coma: an unresponsive state.

level of consciousness chart

Orientation

Then, check the patient’s orientation to person, place, time and situation.

  1. Person: Check that the patient knows who they are, if they answer correctly, they are oriented to person.
  2. Place: Check that the patient knows where they are, if they answer correctly, they are oriented to place.
  3. Time: Check that the patient knows what day it is, if they answer correctly, they are oriented to time.
  4. Situation: Check that the patient knows why they are at the clinic/health care facility, if they answer correctly, they are oriented to the situation.

Now if the patient answers all four orientation questions accurately, this means that they are oriented to person, place, time and situation or you can simply say that they are oriented times four (X 4) .

General appearance

nursing assessment documentation

Next, observe the patient’s general appearance in the following categories:

  • Affect/behaviour/anxiety
  • Level of hygiene
  • Body position
  • Patient mobility
  • For patient’s with hearing aids, check that they can hear you
  • Check speech pattern and articulation

Note: any deviation from the normal may reflect neurological impairment, oral injury or impairment, improperly fitting dentures, differences in dialect or language, or potential mental illness. Any abnormal findings should be followed up with a focused assessment, as needed.

Head and neck Assessment

Inspectionhead to toe nursing assessment tool

  • Inspect eyes for drainage: Check eyes for drainage, pupil size, and reaction to light. Drainage may indicate infection, allergy, or injury.
  • Inspect mouth, tongue, and teeth for moisture, colour, dentures. A dry mucous membranes may indicate dehydration.
  • Inspect for facial symmetry, if there is facial asymmetry, it may indicate neurological injury or impairment.

Eye Examinations

  1. Test for Visual acuity using the Snellen eye chart:

printable snellen eye chart

  • To access visual acuity for the right eye, ask the individual to hold a snellen eye exam chartcard over the left eye and stand 20 feet away from the Snellen chart and ask them to read each line of letters.
  • If the individual correctly reads all the letters in a line, they can move on to the next line.
  • Ask the individual to read all the letters until they are unable to see the letters clearly or until they get to the smallest line of letters that they are unable to read.
  • Record score for the right eye
  • Repeat steps for the left eye
  • normal visual acuity is 20/20 which means that the person can read the same line of letters at 20 feet what a normal eyes can read at 20 feet.

2. Test for Visual fields using the confrontation test:confrontation test for eyes

  • This is test is used to assess cranial nerve II
  • Begin by covering one eye and have the patient cover the opposite eye. Ask them to face you and look at you while doing this.
  • Then wiggle your fingers diagonally up, middle and down on either side of the patient’s head and ask them to say “now” as soon as they see your fingers.
  • Normally the person should see your fingers the same time as you do.

Note: in relation to the anterior posterior axis of the eye, the person should be able to see your fingers at about 50 degrees superiorly, 60 degrees nasally, 90 degrees temporally, 70 degrees inferiorly.

confrontation eye test

3. Test for Extraocular Muscle Reflex using the Corneal Light Reflex:

  • Take a penlight, ask the patient to stare straight ahead and shine the light into their eyes from about 12 inches away, note the light reflection on their cornea, it should be on exactly the same spot on each eye.
  • Then perform the Diagnostic positions test to elicit muscle weakness. Then ask the patient to follow your hands, with your fingers about 12 inches from their eye move it to the six cardinal positions (assesses cranial nerve III, IV & VI), you should see smooth parallel eye movements, there should be no lid lag, during extreme lateral movements mild nystagmus is normal but in any other position it is not.

Eye Assessment Using PERRLA

PERRLA eye acronym simply stands for: pupils are equal round and reactive to light and accommodation.perrla eye assessment

  • Check that the pupils of both eyes are round and equal
  • Check the diameter of the pupil: normal adult pupil size should vary from 2-4 millimeter in bright light and 4-8 millimeter in dim light.

Test for pupillary light reflex: with the room darkened slightly shine the light on the eyes both pupils should react briskly.corneal light reflex exam

Then test for accommodation by wiggling your fingers back and forth and asking the patient to follow your finger. Notice as the pupil dilate and constrict and show convergence, if this happens then it means that the pupils show accommodation.

perrla eye exam
Abnormal findings from the PERRLA eye exam

Please note: any unusual eye and neck findings may suggest neurological damage and should be followed up with a focused neurological system assessment.

Cardiovascular Assessment

Neck vessels

Inspection

  • with the person lying at a 30 degree angle, examine the neck vessels. First inspect each side of the neck and the suprasternal notch for the jugular vein and the jugular venous pulsation, estimate the jugular venous pressure using 2 rulers to measure.
  • Inspect the carotid pulse on the side of the neck.

Auscultationdo head to toe assessment

Auscultate for carotid bruit if indicated using the bell of the stethoscope, ask the patient to take a deep breath and hold it so that you can listen clearly for the bruit.

Extremities

Inspecting the extremities

  • Arms and legs for pain, deformity, edema, pressure areas, bruises, compare bilaterally
  • Check radial pulse and dorsalis pedis pulse on both extremities and compare bilaterally.
  • Note the amplitude of the radial and dorsalis pedis pulse (on a scale of 0 – 4)
    • 0 indicates no palpable pulse
    • + 1 indicates a faint, thready but detectable pulse
    • + 2 indicates a weak but palpable pulse, but slightly diminished pulse than +3
    • + 3 indicates a palpable pulse, normal pulse amplitude is +3
    • + 4 indicates a bounding pulse
  • Check for clubbing:head to toe assessment tool
    • Clubbing of nails is when the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis.

Palpating the extremities

  • Radial pulses
  • CWMS (colour, warmth, movement, and sensation)
  • Pedal pulses: dorsalis pedis and posterior tibial
  • Capillary refill (hands and feet) under 3 seconds, report if it’s more than 3 secs

To check capillary refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction. Unusual findings should be followed up with a focused cardiovascular assessment.

Precordium and Heart

cardiac assessment nursing

Inspection

  • With the person lying down inspect the precordium for any abnormal pulsation such as heaves.

Palpation

  • Palpate the apical impulse and note its location
  • Palpate the precordium to detect any abnormal pulsation such as thrills (palpable vibration).

Ascultation

  • Auscultate the apical rate and rhythm
  • Use the diaphragm of the stethoscope to auscultate the first and second heart sounds from the base to the apex.
  • Use the bell to auscultate for extra heart sounds and murmurs.
  • Ask to person to lie on their left side and auscultate at the apex with the bell to detect any extra heart sounds.
  • Auscultating for Heart sounds and murmurs: While the person is sitted ask them to lean forward slightly and auscultate the base of the heart for heart sounds and then auscultate on the right and left side of the the sternum to detect any murmurs.

What are the Landmarks for cardiac auscultation?

5 areas for cardiac auscultation

  • Second intercostal space right sternal border, base of the heart – Aortic valve area.
  • Second intercostal space left sternal border, base of the heart – Pulmonic valve area, S2 which is the closure of the semilunar valve is louder than S1.
  • Third intercostal space left sternal border –Erb’s point.
  • Fourth intercostal space left sternal border – Tricuspid valve.
  • Fifth intercostal space near the left midclavicular line –Mitral valve (Apical pulse area), this is the apex of the heart and over here S1 which is the closure of the atrioventricular valves is louder than S2.

A useful way that I use to remember my cardiac landmark is by using the MNEMONIC “A PET MONKEY”

A = Aortic

P = Pulmonic

E = Erb’s point

T = Tricuspid

MONKEY = Mitral

The different Heart sounds

  • S1 (lubb) – the closure of the AV valves (mitral & tricuspid), heard best at the apex of the heart.
  • S2 (dubb) – Closure of the semilunar valves (pulmonic and aortic), heard best at the base of the heart.
  • S3 – referred to as diastolic filling sound or extra heart sound, results from ventricular vibration secondary to rapid ventricular filling, can be heard in early diastole using the bell of the stethoscope. S3 heart sounds is common in children, pregnant females and well trained athletes.
  • S4 – diastolic filling sound or extra heart sound, results from ventricular vibration secondary to ventricular resistance, heard best in late diastole. Almost always abnormal when heard.

What are murmurs?types heart murmurs

Murmurs are blowing or wooshing sounds from turbulent blood flow. Conditions that cause murmurs include:

  • Increased blood flow velocity e.g. clogged artery
  • Structural valve defects e.g. congenital heart defects
  • Valve malfunction
  • Abnormal chamber opening e.g. septal defect.

Lung/ Pulmonary Assessments

lung sounds nursing assessment

Anterior chest wall of the Lung

Inspection

Face the person to exam the anterior chest wall:

  • Inspect respirations and skin characteristics (lumps, bumps, lesions).
  • check to see that the anterior posterior diameter is less than your transverse diameter by a ratio of 1:2, this is a normal finding, it means that the patient does not have a barrel chest which is common in individuals with chronic obstructive pulmonary disease (COPD).

Palpation

  • Tactile fremitus: ask the person to say “99” or “blue moon” everytime they feel your hands on their chest. Tactile fremitus is the vibration that is felt on the chest wall as the patient speaks.
  • Tactile fremitus should be present and equal bilaterally on both lungs and it should fade as you go down the lungs.
  • Palpate for any lumps or tenderness. Ask the patient to inform you if they start to feel any pain or tenderness.

Percuss

  • Percuss the anterior lung fields percussing from side to side.
  • During percussion, resonance should be heard over lung fields as this means that there is no inflammation of lung fields.

Auscultation

breath sounds nursing assessment

  • Ask the person to breathe in through their mouth, following the same pattern auscultate the breath sound and note any adventitious breath sounds.
  • During auscultation around the sternum you should hear bronchovesicular sounds and when auscultating towards the periphery you should hear vesicular sounds.

Posterior chest wall of the Lung

Inspection

  • Examine and inspect the posterior chest.
  • Note the configuration of the thoracic cage.
  • Skin characteristics (lumps, bumps, lesions).
  • Symmetry of shoulders and muscle.

Palpation

  • Symmetrical chest expansion: ask the person to take a deep breath in through their mouth.
  • Tactile fremitus: ask the person to say 99 or blue moon every time they feel your hands on their back.
  • Palpate for any lumps or tenderness
  • Palpate down the spine in a spiral motion to assess the spinous processes.

Percuss

  • Percuss the costovertebral angle to detect any tenderness.
  • Percuss the posterior and lateral lung fields, percuss to map out the lower lung border on exhalation and inhalation mark the point and measure the difference to estimate Diaphragmatic excursion.
  • During percussion, resonance should be heard over lung fields as this means that there is no inflammation of lung fields. If a dull sound is heard it means that there may be inflammation, fluid or tumors in the lungs.

Note: in children and thin adults it is normal to hear hyperresonance during percussion of the lungs.

Auscultation

  • Auscultate the breath sound and note any adventitious breath sounds
  • Check for clear breath sounds, good air entry equal bilaterally and the absence of adventitious sounds.
  • Normally, you should hear bronchovesicular sounds between the scapula, in this location you will notice that you hear the sound inspiration and expiration equal bilaterally.
  • As you move to the peripheral, listen for vesicular sounds. At the periphery, expiration is louder than inspiration.

Abdomen

  • For abdominal assessment the sequence is inspection, auscultation, percussion and palpation. In essence, you have to auscultate before palpation or percussion the abdomen because touching the abdomen during assessment can stimulate bowel activity and this can affect the accuracy of your assessment.
  • To begin the assessment of the abdomen. First lower the bed to the normal and ensure that the bed is flat and the patient is lying in a supine position.

Note: abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis. Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.

Inspection

  • Bend down or squat in front of the patient to inspection the contour of the patient’s abdomen. It should be flat. The umbilicus should be midline and inverted.
  • Standing from the corner of the room note the absence of discoloration or blueness around the umbilicus which is indicative of cullen’s sign.
  • Observe the abdomen for symmetry by asking the patient to take a deep breath and do a sit up.

Auscultation

abdominal percussion assessment

  • Using the diaphragm of the stethoscope auscultate the patient’s bowel sounds starting from the Lower left quadrant. Spend at least 5 seconds on each quadrant. Note the quality of the bowel sound (is it hyperactive, hypoactive or normal).
      • Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum.
      • Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.
      • Normal bowel sounds should be heard in all four quadrants.
  • To auscultate for vascular sound, ask the patient to exhale and hold
    • Using the bell of my stethoscope, auscultate for vascular sounds by starting with aorta, left renal artery, right renal artery, right iliac artery, left iliac artery, left femoral, right femoral artery.
    • No vascular sounds or bruit should be heard, as that is a normal finding.

Percussion

  • Percuss 2 times in 3 aspects of abdomen on both sides and 12 times in total.
  • General tympany should be heard in all 4 quadrants as that is a normal finding.

Palpation

abdominal nursing assessment

  • Start with light palpation, ask the patient if they feel any pain. Feel for lumps and bumps and observe patient for involuntary guarding during procedure. If no pain, lumps or bumps move to deep palpation.
  • For deep palpation, use pads of finger to push deeply into the abdomen, feel for rigidity, lumps bumps or swollen organs. It is normal to find none in a healthy individual.
  • Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis.

Note: deep palpation may be contraindicated in patient’s with certain disorder, please check that the patient does not have any disease or disorder that contraindicates deep palpation.

Genitourinary

  • Check patient’s urine output for frequency, colour and odour.
    • Frequency:
      • This is the urge to urinate several time a day or at night (nocturia) or a combination of both.
    • Colour:
      • The normal urine colour is anywhere from straw colour to gold. Urine can be lighter and darker in colour as well. If your urine is very light shade it means you have been drinking a lot of water and if your urine is dark coloured it may mean that you have not been drinking enough and may be dehydrated. It can also be a sign of liver problems.
    • Odour:
      • The odour of urine can give an indication of how healthy an individual is and how much water they drink. most times urie does not have a foul smelling odor, foul smelling urine may be indicative of presence of bacteria, diabetes patient’s or individual with rare metabolic disease usually have a sweet smelling urine.
  • Lastly, determine frequency and type of bowel movements.

Note: unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment.

Musculoskeletal and 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.

Documentation

head toe assessment form pdf

  • This is the last but important step to any full head to toe assessment or focused assessment
  • Report and document assessment findings and related health problems as per agency policy. All abnormal findings must be reported and documented in a timely fashion to promote patient’s safety.

If you have any comments, feedback or questions. I would like to hear from you.

kindly share them in the comment section below.

Thank you for reading

Warm Regards

Pam