Head to toe - Head to toe assessment PDF

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Summary

Head to toe assessment ...

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Introduction:     

Introduce yourself and gel in Close curtain Verify patient by name and DOB against their wristband Make sure patient has no questions Ask about allergies

General Survey:     

A&O X 4 o Person, place, time, situation Posture o Patient is upright Skin Color o Appropriate for ethnicity? Dress o Appropriate for weather? Hygiene Practices o Is the patient clean? Any odors?

Head, Eyes, Nose, Mouth, Face, and Neck:   

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Inspect the head and scalp o Lesions? Tenderness? Hair loss? Normal size? Palpate sinuses o Tenderness? Swelling? Palpate Lymph Nodes o Preauricular o Postauricular o Tonsillar (Jugulo-digastric) o Submandibular o Submental o Superficial Cervical o Posterior Cervical o Deep Cervical Chain o Supraclavicular Eyebrows and eyelashes o Symmetry? o Discharge from eyelashes?

Eyes:   

Sclera and Conjunctiva o Sclera should be white, conjunctiva should be pink Look into eyes with ophthalmoscope for Red Reflex Snellen chart o Testing Cranial Nerve II (Olfactory) o One eye at a time o If patient gets more than 3 wrong, move up to next line

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Check pupils with penlight o Pupils are equal, round, reactive to light, and o Accommodative  Have patient look at object in the distance and back to you  Pupils should dilate at distance and constrict back at you  6 Cardinal signs o Up right, Mid right, Lower right, Up left, Mid left, Lower left o Checks cranial nerves III (oculomotor, IV (trochlear), and VI (abducens)  Confrontation test o Check peripheral vision (wiggling finger) o Patient should see finger at the same time as nurse or sooner

Nose:  

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Palpate nose for tenderness Check for obstruction o Have patient cover each nostril one at a time and breathe in through nose o If you did hear obstruction, check with pen light Test for sense of smell with eyes closed o Ask patient to identify smell

Ears: 

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Inspect and Palpate Pinna & Tragus o No swelling, redness, discharge, tenderness o Have patient close each side of tragus for tenderness Look into ear with otoscope o Pull pinna o Look for pearly gray tympanic membrane o Check for cone of light  Left side at 7 o’clock  Right side at 5 o’clock Whisper Test o Whisper three letters/numbers to patient and have them repeat them o Checking Cranial Nerve VIII Weber Test o Use tuning fork and place it in middle of patient’s head; patient should hear it bilaterally Rinne Test o Use tuning fork and place on mastoid bone behind ear, tell patient to let you know when they stop feeling it and moving tuning fork to their ear; patient should still hear it o Air conduction > Bone conduction

Mouth:  

Inspect lips o Are they moist and pink? Any lesions? Use tongue depressor to insect mouth and throat o Look for cavities, lesions, sores, dentures, swelling, abnormal coloring of the tongue

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o Is uvula midline? Initiate gag reflex and swallow mechanism o Checking for cranial nerves IX (glossopharyngeal) and X (vagus) Tongue movement o Patient will stick out tongue and move from left to right  Checking for cranial nerve XII (hypoglossal)

Face and Neck: 

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Cotton swab test & TMJ o Have patient different between dull and soft on both cheeks, forehead, and chin o For TMJ, place hands on mandible bone; have patient open and close jaw  Checking for Cranial Nerve V (trigeminal) Test Cranial Nerve VII (facial) o Smile, frown, puff out cheeks, lift eyebrows Test Cranial Nerve XI (accessory) o Have patient push cheeks against hand and lift shoulder against the palms of your hand Check to make sure the Trachea is midline Palpate Thyroid o Should not feel unless there is swelling or nodular masses

Heart, Lungs, and Back: Heart: 

Auscultation points on heart: o Aortic: 2nd intercostal space, right sternal border o Pulmonic: 2nd intercostal space, left sternal border o Erb’s Point: 3rd intercostal space, left sternal border o Tricuspid: 4th intercostal space, left sternal border o Mitral: 5th intercostal space, midclavicular line  Apical pulse is found here

Back and Lungs:  

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Inspect back o Check for moles, lesions, and symmetry Check for Posterior Symmetry o Place hands around T9-10 and have patient take deep breath o Checking for symmetric expansion of the ribcage Tactile Fremitus o Use palmar surface of hand o Have patient recite “Blue moon” o 10 times total, 5 times each side Percussion o Use hammer o 18 times total, 9 times each side

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o Resonance over normal lung o Hyperresonance will be present in emphysema patients Auscultation o 18 times total, 9 times each side o Bronchial (high pitched, high amplitude), Bronchovesicular (moderate pitch, moderate amplitude), Vesicular (low pitch, soft amplitude) Voice sounds o Bronchophony  Patient will say “99”; should be muffled  If you hear clearly, patient has area of consolidation  18 times total, 9 times each side o Egophony  Patient will say “EE-EE-EE”; should hear EE-EE-EE  If you hear AH-AH-AH, patient has area of consolidation o Whisper test  Patient will whisper 1234  Should not hear it, if you do, patient has area of consolidation

Heart cont. while patient on bed:  

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Check for Jugular Vein Distension o Have patient lay down, put head of bed up 30-45 degrees Palpation of pulses: o Temporal, Carotid, Brachial, Radial, Femoral, Popliteal, Posterior Tibialis, Dorsalis Pedis Inspect, palpate, and auscultate the Carotid o Should only hear breath sounds o If you hear bruit (swooshing of blood), that is abnormal finding

Abdomen: PATIENT WILL EMPTY BLADDER BEFORE ASSESSMENT  

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Inspect abdomen o Check for contour, lesions, scars, hernias Auscultation o RLQ, RUQ, LUQ, LLQ o Note if bowel sounds are present  Present? Hyperactive? Hypoactive? Borborygmus? Absent? o If no sound is heard, listen for 5 minutes Percussion o Same order as auscultation o Tympany heard over open space, dull heard over organs Light palpation o Check for tenderness Deep palpation o Check for tenderness

GU system:

We will NOT be assessing this system, however, know what to look for 

Inspect GU o Check for lesions, color, incontinence, odors

Skin and Musculoskeletal: Skin:  

Check skin integrity o Back of neck, shoulder, elbow, coccyx area, heels of feet Palpate ankles for edema

Musculoskeletal: Completed while patient is lying down        

Point toes toward head, point towards toward floor o Check for dorsiflexion, plantar flexion Have patient push feet toward palm of hand, and pull up against palm o Checks for strength and resistance Circumduction of ankles o Move ankles in circle Inversion, eversion of ankles o Moving ankles inward, moving ankles outward Flexion and extension of knees o Have patient bend knee, have patient straighten knee Internal and external rotation of hips o Have patient bend one knee at a time and turn from one side to the other Strength and resistance of legs o Have patient push legs towards hands, and pull up away from hands Abduction and Adduction of hips o Have patient move leg away from and toward the body Have patient sit at edge of bed or stand

Head: 

Head rotation o Ear to shoulder o Stretch head backward and forward

Shoulders:   

Abduction and adduction of shoulders o Drop test Shoulder strength and resistance o Have patient hold their arms in adducted position, patient will push up against your hands, then push down against your hands External rotation and internal rotation of shoulder

Arms: 

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Flexion and Extension of arms o In flexion, arms bent o In extension, arms straight Arm strength and resistance o Have patient flex arms and pull toward them while nurse resisting, then have patient push toward nurse

Hands/Wrists: 

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Flexion and Extension of hands o In flexon, hands pointed down o In extension, hands pointed up Ulnar and Radial Deviation o In Ulnar, wrist pointed away o In Radial, wrist pointed toward Abduction and adduction in fingers o Abduction, fingers spread o Adduction, fingers together Strength in fingers o Have patient gently squeeze two of your fingers on each hand Skin turgor o Check skin for temperature and elasticity Capillary refill o Press down on nail bed and release o Should refill less than 3 seconds Check for clubbing of nails o Clubbing = Hypoxia Graphesthesia o Have patient close eyes and write a letter or number in the palm of patient hand and have them identify what was written Stereognosis o Have patient close eyes and hand patient an object and patient identify object Phalen test (carpal tunnel) o Have patient put backs of hands together in a flexed position o Note if any pain is present Tinnel test on median nerve (carpal tunnel) o Tap patient in the middle of the wrist on median nerve o Note if any pain is present Have patient stand

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Lateral bending o Bend to the left and to the right Bend back and bend forward o Have patient bend forward toward toes to check for scoliosis Romberg test

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o Have patient stand with eyes closed and legs together to assess balance Coordination test o Have patient touch nose and then nurse finger; left, middle, right Assess gait o Is patient walking normal, limping, waddling, shuffling, etc? Tandem test o Have patient walk heel to toe Recall test o Give patient three words to memorize, nurse will continue with assessment and then ask patient to recall the words Check for judgement o Ask patient a question that would help determine their character and judgement o After this assessment is completed, ask patient to recall words you told them Have patient sit at the edge of bed

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Check reflexes o Tricep o Bicep o Brachioradialis o Patellar o Achilles Have patient lie down

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Babinski test o Draw an upside J with hammer, starting at heel of the foot, curving toward toes o If toes flare, patient may have neurological disorder o A positive babinski sign is normal in infant up until the age of 2 ½...