Question

Head to toe assessment

HOW TO WRITE: YOU ARE TO CREATE A PICTURE OF YOUR PATIENT

General appearance:

• Affect/behaviour/anxiety

• Level of hygiene

• Body position

• Patient mobility

• Speech pattern and articulation

This is not a specific step. Evaluating the skin, hair, and nails is an ongoing element of a full body assessment as you work through steps 3-9.

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.

Head and neck:

• Inspect eyes for drainage.

• Inspect eyes for pupillary reaction to light.

• Inspect mouth, tongue, and teeth for moisture, colour, dentures.

• Inspect for facial symmetry.

4. Chest:

• Inspect:

  • Expansion/retraction of chest wall/work of breathing and/or accessory muscle use

  • Jugular distension

• Auscultate:

  • For breath sounds anteriorly and posteriorly

  • Apices and bases for any adventitious sounds

  • Apical heart rate/rhythm

• Palpate:

  • For symmetrical lung expansion

• Breasts

Abdomen/GI:

• 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, odour.

• Determine frequency and type of bowel movements.

Genitourinary:

Check urine output for frequency, colour, odour.

Female: vaginal discharge

Male: circumcision, discharge

Musculoskeletal:

• Check if full or partial weight-bearing.

• Determine gait/balance.

• Determine need for and use of assistive devices.

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).

Back area (turn patient to side or ask to sit up or lean forward):

• Inspect back and spine.

• Inspect coccyx/buttocks.

Tubes, drains, dressings, and IVs:

• Inspect for drainage, position, and function.

• Assess wounds for unusual drainage.

Sample format for documentation:

General Status

Vital signs

Head, Ears, Eyes, Nose, Throat

Neck

Respiratory

Cardiac

Abdomen/GI

GU

Pulses

Extremities

Skin

Neurological

Answer 1

1. General appearance:

Affect/behaviour/anxiety - Normal behaviour

Level of hygiene - Good hygiene maintained

Body position - Normal posture

Patient mobility - Normal gait and mobility

Speech pattern and articulation - Normal speech pattern

2. Skin, hair, and nails:

Inspect for lesions, bruising, and rashes. - No bruises , rashes.

Palpate skin for temperature, moisture, and texture. - Normal temperature , , moisture and texture

Inspect for pressure areas. - No pressure sores

Inspect skin for edema. - No edema

Inspect scalp for lesions and hair and scalp for presence of lice and/or nits. - Normal scalp , no dryness and dandruff

Inspect nails for consistency, colour, and capillary refill. - Normal ,trimmed nails

Head and neck:

Inspect eyes for drainage. - No drainage

Inspect eyes for pupillary reaction to light. - Both are reactive

Inspect mouth, tongue, and teeth for moisture, colour, dentures. - normal

Inspect for facial symmetry. - normal facial structure

4. Chest:

Inspect:

Expansion/retraction of chest wall/work of breathing and/or accessory muscle use - normal expansion and retraction , no use of accessory muscle

Jugular distension - no distension

Auscultate:

For breath sounds anteriorly and posteriorly - normal

Apices and bases for any adventitious sounds - normal

Apical heart rate/rhythm - normal heart rate

Palpate:

For symmetrical lung expansion - normal symmetrical expansion

Breasts - normal shape , nipple and areola

Abdomen/GI:

Inspect:

Abdomen for distension, asymmetry - no distension and ascitis and it's symmetrical

Auscultate:

Bowel sounds (RLQ) - normal bowel sounds

Palpate:

Four quadrants for pain and bladder/bowel distension (light palpation only) - no inflammation , tenderness ,normal organs on palpation

Check urine output for frequency, colour, odour. - normal colour ,odour and frequency

Determine frequency and type of bowel movements. - 2 times per day ,normal bowel movements

Genitourinary:

Female: vaginal discharge - normal

Male: circumcision, discharge - NA

Musculoskeletal:

Check if full or partial weight-bearing. - full weight bearing

Determine gait/balance. - normal

Determine need for and use of assistive devices. - no need for any assistance

Inspect:

Arms and legs for pain, deformity, edema, pressure areas, bruises - normal

Compare bilaterally

Palpate:

Radial pulses - normal pulse

Pedal pulses: dorsalis pedis and posterior tibial - present

CWMS and capillary refill (hands and feet) less than 3sec

Assess handgrip strength and equality. - good strength and equality

Assess dorsiflex and plantarflex feet against resistance (note strength and equality). - normal strength and equality

Back area (turn patient to side or ask to sit up or lean forward): - normal skin ,pressure sores

Inspect back and spine. - normal

Inspect coccyx/buttocks. - normal

Tubes, drains, dressings, and IVs: NA

Inspect for drainage, position, and function. - NA

Assess wounds for unusual drainage. - NA

Sample format for documentation:

General Status - Patient is stable with normal vitals

Vital signs - normal

Head, Ears, Eyes, Nose, Throat - normal ,no deformities

Neck - normal

Respiratory - normal

Cardiac - normal

Abdomen/GI - normal

GU - normal

Pulses - normal pulse

Extremities - normal

Skin - normal

Neurological - normal