Question

How to document a complete head to toe assessment correctly. Physical assessment

Answer 1

Physical Assessment

Physical Assessment or the Physical Examination is a routine test conducted by a physician or nurse through a complete head to toe assessment. The methods used for physical examination are Inspection, palpation, percussion and Auscultation.

Articles used for Physical Examination/ health examination:

- Gloves

- Thermometer , Blood pressure Apparatus, watch

- Stethoscope

- scale, inch tape, weghing machine

- Small diary, pen / pencil

( Otoscope, ophthamoscope, reflex hammer, If needed)

Preliminary steps:

Provide privacy to the patient

Perform hand washing

Introduce yourself and explain the procedure to the patient

Confirm Patient's Identity by asking name and date of birth of the patient and looking at his wrist band .

Head to toe Assessment :  

General appearance and health status

General appearance and Consciousness  : look their age / alert / drowsy/ proper grooming

Body build : thin / obese / Normal body build

Mood : agitated/ calm / stressed/ crying

Any noted abnormalities

Vital signs :

Temperature, Pulse, respiration and Blood pressure

Obtain the oxygen saturation and Pain level ( if needed)

Height, Weight and BMI ( body mass index)

BMI = weight ( kg)/ height in ( meter square)

( 18.5- 24.9 : normal range, more than 25 : overweight)

Head : Hair and face

Hair distribution: Symmetrical / asymmetrical  , level of ears and eyes, any lesions on the head and face , presence of lies/ dandruff

Face: Symmetrical/ drooping of eye or lips ( bells palsy)

Eyes: swelling of eyelid, discoloration of sclera ( jaundice), conjunctiva : pink or red

Vision: hyperopia/ myopia/ double vision

Ears: any abnormal discharge, intact pinna, hearing ( normal/ decreased)

Nose: Symmetrical, septal deviation, drainage, dry , mass

Mouth and oral cavity and throat : dry lips, lesions, dental carries, discoloration of teeth, swollen and red tonsils, coated tongue

Neck : Enlargement of thyroid or lymph nodes

Chest

Symmetrical/ asymmetrical

Respiratory: Ausculate for any abnormal breath sounds ( wheezing, whistling, cheyne- stoke respiration, crackling)

Cardiac: Normal lub dub sound , Ausculate for any abnormal sounds like aortic regurgitation

Abdomen :

Inspection; presence of scars or masses

Auscultation : bowel sounds , normal/ hypo/ hyperactive

Percussion: presence of fluid or gas collection

Palpation : any hepato megaly / spleeno megaly, any tenderness

Assess anal area for any hemorrhoids, masses

Assess the bowel pattern

Genito urinary system : Incontinence or retention of urine, abnormal discharge , presence of STDs

Extrimities: Upper and lower

Ispect for any deformities, bruises, pressure areas , clubbing of nais, nail colour

Palpate for apical and pedal pulses

Check the Range of Motion ( if permitted)

skin : warmth, dry, excessive sweating , lesions, colour changes, presence of any skin disorders

Back: inspect for any spinal abnormal curvatures ( scoliosis, kyphosis), pressure ulcers..etc.

Neurological examination/ cranial nerve examination ( as indicated