head to toe assessments 1) general overview: appearance, posture, grooming, mental state, vs, ht...

Head To Toe Assessments

1) General Overview: appearance, posture, grooming, mental state, VS, HT & WT

2) Integumentary System: skin, hair, & nails

3) Head: eyes, ears, oral-pharyngeal cavity, lymph nodes of the neck

4) Breast

5) Chest & Lungs (Respiratory Assessment)

Head to Toe Assessments

6) Cardiovascular system

7) Abdomen (Gastrointestinal system)

8) Musculo-skeletal system

9) Neurological system

10) Genitourinary system

Head-To-Toe Assessment: Objectives

At the completion of this unit you will be able to:

1) Explain and demonstrate the components of a head-to-toe-assessment

2) Compare and contrast normal and abnormal assessment findings.

Integumentary Assessment


ColorColor: Varies according to age, culture,

ethnicity (pigmentation) Exposed areas are usually darker Variations with neonates & infants Capillary hemangiomas Common Color Variations (p. 441

box21-5)


Temperature:Temperature: Use dorsum of hand Normally skin is warm, but varies with

environmental temperature Causes of coolness: hypothyroidism,

poor peripheral circulation, shock Causes of warmth: hyperthyroidism,

infection, inflammatory responses


Moisture:Moisture: Normal skin: warm & dry Excessive moisture: hyperthermia,

hyperthyroid, & anxiety. Hyperhidrosis = excessive sweating Dry skin: dehydration, CRF,

Hypothyroidism, excessive sun exposure, harsh soaps


Skin Turgor:Skin Turgor: Turgor = elasticity of skin. Pinch test Tenting: > 3 seconds to return to

natural position. Dehydration and loss of skin elasticity

decreased turgor (tenting)


Edema: Edema: excessive amount of fluid in the tissues.

Abnormal finding Causes: compromised CV status,

kidney disease, PVD, ↓ albumin levels Assessing edema & pitting edema:

(p.442, fig. 21-19 & box 21-7)


Skin Lesions:Skin Lesions: Primary skin lesion: result directly from disease

or condition; i.e.: acne, solar lentigines Secondary skin lesion: result from generalized

illness. i.e.: plaques from psoriasis, ulcers from poor peripheral perfusion.

Evaluate for size, shape, pattern, color, distribution, tenderness, pain, itching, etc.

Integumentary Assessment: Skin Lesions

Solar Lentigines Psoriasis

(Seborrheic Keratosis) Plaques


Examples of Skin Lesions:Examples of Skin Lesions: Normal variations: milia, nevi, skin tags,

freckles, striae, birthmarks Primary lesions: macule, papule, vesicle,

wheal, pustule Secondary lesions: fissure, ulcer, scales,

scar, keloid, plaque, crusts


Hair:Hair: Color: i.e. graying, albinism Texture: i.e.: fine VS. coarse Distribution: hair is normally evenly distributed. Men have more facial and body hair Alopecia: hair loss; may be normal or abnormal Patchy hair loss: i.e.: fungal infections, or

autoimmune disorder


Male & Female Pubic Hair Patterns

Diamond Triangle


Hair:Hair: Hirsutism: excessive facial or trunk hair.

May result from steroid use or endocrine disorders.

Scalp: normally smooth, firm, symmetrical, nontender, & without lesions

Abnormalities: scales, fungal infection, psoriasis, fungal infection, cradle cap


Cradle cap: scaling of an infants head


Nails:Nails: Assessments: Color Shape Texture Variations in color, shape, or texture may

indicate health problems


Nail Color:Nail Color: Pale or cyanotic (nail beds): i.e. anemia,

hypoxia, respiratory disorders, CV disorders Mee’s lines: transverse white lines in the nail

bed. Splinter hemorrhages: associates with

trauma and bacterial endocarditis. White spots: may indicate zinc deficiency


Finger nail ridges Beau’s Lines(Vertical = Normal) (Associated with

Malnutrition, chemo,

& metabolic abnorms)


Nail Shape:Nail Shape: Normal angle of nail is about160º Nail clubbing: nail plate angle > 180º;

associated with long-term hypoxia (i.e.: COPD) Spoon shape nails may result from zinc

deficiency Nail clubbing


Nail Texture:Nail Texture: Normal = smooth Thickened: poor circulation Yellowing with thickening: fungal infection

(onychomycosis) Brittle nails: hyperthyroidism, malnutrition,

calcium or iron deficiency, repeated use of harsh nail products.

Soft or boggy nails: seen with poor oxygenation

Head Assessment

Includes

Head

Eyes

Ears

Nose

Throat

Head Assessment

Head & Face Assessment

Head Assessment

Skull & Face:Skull & Face: Normal = skull rounded,

face symmetrical in appearance & in movement.

Acromegaly: a large head during adolescence or adulthood

Micromegaly: abnormally small head

Head Assessment

Skull & Face:Skull & Face: Head flattening or abnormal shape: i.e.

trauma during vaginal birth, placing baby in same position for several hours.

Hydrocephalus: accumulation of cerebrospinal fluid cause the head to enlarge in infants & children

Head Assessment

Skull & Face:Skull & Face: Facial or head asymmetry may result

from trauma, paralysis, or occur congenitally.

Skull should be smooth to palpation with not unusual bulges or contours.

Jaw motion should be symmetrical, painless, & without clicking or crepitus.

Head Assessment

Eyes:Eyes:

Snellen chart

Head Assessment

Eyes:Eyes: Focused history questions Pterygium: a growth or thickening of

the conjunctiva

Head Assessment

Eyes:Eyes: Sclera: normally smooth, glistening,

white, & with tiny vessels visible. Yellow sclera: icteric Arcus senilis: a white ring encircling

the rim of the cornea

Head Assessment

Eyes:Eyes: Pupils: normally equal, round, reactive to

light, & accommodate (PERRLA). Constricted pupils: 2 cm or less Dilated pupils 5-6 cm. Normal/usual size: 3-4 cm. Pupil accommodation: bilateral pupils dilate

or constrict equally as eyes converge on an object as it moves nearer or further.

Head Assessment

Dilated pupilDilated pupil Constricted pupilConstricted pupil

Head Assessment

Eyes:Eyes: Snellen chart: distance vision, prescribed

lenses should be worn during exam The top number of the fraction indicates the

distance the person was standing from the chart.

The bottom number is the distance at which a person with normal vision can read the chart. i.e.: 20/30

Head Assessment

Eyes:Eyes: Myopia: diminished distance vision Anisocoria: unequal pupils Color blindness: inability to distinguish

color (ishihara cards) Extraoccular movements (EOMs):

visual fields

Head Assessment: Eyes, ishihara cards

Head Assessment

Eyes:Eyes: Peripheral vision: the boundaries of

the visual fields while the eye is in a fixed position.

Opthalmoscope used to examine the internal structures of the eye.

Head Assessment

Ears & hearing: Ears & hearing: InspectionInspection External ear: sound be symmetrical, equal in External ear: sound be symmetrical, equal in

& appearance& appearance Pinna normally at the level of the corner of Pinna normally at the level of the corner of

the eye. the eye. Abnormal placement may indicate genetic Abnormal placement may indicate genetic

disorders (I.e.: Down syndrome) or hearing disorders (I.e.: Down syndrome) or hearing deficits.deficits.

Head Assessment

Ears & hearing: Ears & hearing:

Head Assessment

Ears & hearing: Ears & hearing: PalpationPalpation External ear is normally smooth, External ear is normally smooth,

pliable, nontender, & without nodules. pliable, nontender, & without nodules. Painful or tender auricles may indicate Painful or tender auricles may indicate

otitis externa. Tenderness behind the otitis externa. Tenderness behind the ear may indicate otitis mediaear may indicate otitis media

Head Assessment

Ears & hearing: Ears & hearing: Middle earMiddle ear Otoscopic examinationOtoscopic examination Examine the auditory canal for cerumen; Examine the auditory canal for cerumen; Chars: black, red, gray, brown, waxy, Chars: black, red, gray, brown, waxy,

odorless, hard or softodorless, hard or soft Tympanic membrane chars: pearly gray, Tympanic membrane chars: pearly gray,

shiny, & translucent. shiny, & translucent.

Head Assessment

Ears & hearing:Ears & hearing: Provide quiet room.Provide quiet room. Whisper test: test for low tones; can Whisper test: test for low tones; can

normally hear and repeat words normally hear and repeat words whispered 1 to 2 feet behind her. whispered 1 to 2 feet behind her.

Watch ticking: test for high tones; can Watch ticking: test for high tones; can normally hear 5 inches from earnormally hear 5 inches from ear

Head Assessment

Ears & hearing:Ears & hearing:Weber test: tuning fork is used to assess Weber test: tuning fork is used to assess

the transmission of sound vibrations the transmission of sound vibrations should generate cranial nerve should generate cranial nerve impulses. impulses.

Rinne test: a tuning fork is used to Rinne test: a tuning fork is used to compare air conduction and bone compare air conduction and bone conduction of sound wavesconduction of sound waves

Head Assessment

Nose & Sinus Assessment:Nose & Sinus Assessment:

History (Subjective data collection): History (Subjective data collection):

List items to includeList items to include

Head Assessment

Head Assessment

Nose & Sinus assessment:Nose & Sinus assessment:

Inspection: should be at midline, smooth, and Inspection: should be at midline, smooth, and without tendernesswithout tenderness

Abnormal findings: asymmetry (trauma or Abnormal findings: asymmetry (trauma or congenital), flaring (respiratory distress), congenital), flaring (respiratory distress), clear drainage( allergy), yellow/green clear drainage( allergy), yellow/green drainage (upper resp. infection), bleeding drainage (upper resp. infection), bleeding (HTN, trauma, bleeding disorder)(HTN, trauma, bleeding disorder)

Head Assessment

Nose & Sinus assessment:Nose & Sinus assessment: Patency: Ask client to close mouth, occlude Patency: Ask client to close mouth, occlude

one naris, & breathe through the other naris.one naris, & breathe through the other naris. A nasal speculum is used to inspect the A nasal speculum is used to inspect the

inner structures of the nose.inner structures of the nose. Nasal mucosa is inspected for color, edema, Nasal mucosa is inspected for color, edema,

lesions, or discharge.lesions, or discharge.

Head Assessment

Nose & Sinus assessment:Nose & Sinus assessment:

Four sets of sinusesFour sets of sinuses The sinuses are palpated for tenderness. The sinuses are palpated for tenderness. Tenderness may indicate infectious or Tenderness may indicate infectious or

allergic sinusitisallergic sinusitis

Head AssessmentFour Sets of Sinuses

Name the four sets of sinuses and locate them on yourself.

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment

History (Subjective data collection): History (Subjective data collection):

List items to includeList items to include

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment Inspect oral mucosa and gums (gingiva)Inspect oral mucosa and gums (gingiva) Oral mucosa & gingiva is normally pink, moist, Oral mucosa & gingiva is normally pink, moist,

intact, and without lesionsintact, and without lesions Abnormal findings: receding gums, sponginess, Abnormal findings: receding gums, sponginess,

bleeding, inflammation, gingival hyperplasia, bleeding, inflammation, gingival hyperplasia, ulcerations, lesions, loose teeth, poor condition of ulcerations, lesions, loose teeth, poor condition of teeth. teeth.

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment Inspect lips & tongueInspect lips & tongue Tongue abnormalities: deviation from midline, Tongue abnormalities: deviation from midline,

limited mobility (cranial nerve deficits), glossitis, dry limited mobility (cranial nerve deficits), glossitis, dry & furry tongue (dehydration), black & hairy tongue & furry tongue (dehydration), black & hairy tongue (fungal infection), absence of papillae, reddened (fungal infection), absence of papillae, reddened mucosa, ulcerations, swelling, nodules, smooth & mucosa, ulcerations, swelling, nodules, smooth & red tongue (iron, B3 or B12 deficiency).red tongue (iron, B3 or B12 deficiency).

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx Assessment The hard palate, soft palate, & oropharynx The hard palate, soft palate, & oropharynx

should be pink, moist & intact. No lesions, should be pink, moist & intact. No lesions, exudate, swelling or discharge should be exudate, swelling or discharge should be present. present.

The uvula is at midline and should rise with The uvula is at midline and should rise with phonation.phonation.

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx AssessmentAbnormal findings: redness, edema, lesions, plaque, Abnormal findings: redness, edema, lesions, plaque,

drainage, reddened or swollen tonsils, white or drainage, reddened or swollen tonsils, white or pale patches of exudate, asymmetrical rise of pale patches of exudate, asymmetrical rise of uvula. uvula.

Tongue abnormalitiesTongue abnormalitiesReview figures 21-8 & 21-9 (p. 430) Review figures 21-8 & 21-9 (p. 430)

Head Assessment

Mouth & Oropharynx AssessmentMouth & Oropharynx AssessmentGag reflex: test by touching the back of the Gag reflex: test by touching the back of the

throat with a tongue blade. throat with a tongue blade. Absence of gag reflex may be seen with Absence of gag reflex may be seen with

over-sedation, head injury, & cranial over-sedation, head injury, & cranial nerve damage as seen with CVA nerve damage as seen with CVA

NECK ASSESSMENT

• Assess for complains of stiffness, pain, difficulty swallowing, or masses/lumps.

Inspect for symmetry, ROM, and visible swollen lymph nodes.

Lymph nodes are gently palpated with one or two finger pads in a circular movement. Palpable lymph nodes descend into the supraclavicular area.

NECK ASSESSMENT

Lymph nodes are found in chains and are generally supple & non palpable.

Lymphadenopathy indicates inflammation or infection in the area that they drain or malignancy.

NECK ASSESSMENT

Lymph

Nodes

NECK ASSESSMENT

The thyroid cartilage, cricoid, hyoid bone, & tracheal rings are palpable and should be at midline.

When assessing the structures of the neck, ask the patient to slightly flex the neck as you lightly palpate.

BREAST & AXILLAE ASSESSMENT

Breast self-examinations is an important health promotion activity.

Breast tissue extends into the axillary area.

Gynecomastia is an abnormal finding in males.

Mastitis: swelling & erythema most often seen with infection.

CHEST & LUNG ASSESSMENT

Pulmonary Structures


Normal ChestNormal Chest: Symmetrical Rises and falls with respiration Diameter expands with inspiration The anteriorposterior to lateral ratio is

1:2.


Chest AbnormalitiesChest Abnormalities:

Kyphosis: Excessive curvature of the thoracic spine

Scoliosis: Lateral curvature of the spine

Barrel Chest: The lateral aspect of the chest is increased. Occurs with COPD


Breath Sounds:Breath Sounds:

Normal: rate 12-20, regular rhythm, unlabored, equal bilaterally

Auscultate breath sounds for one complete respiratory cycle.

Compare breath sounds bilaterally

Preferred position: sitting


Breath Sounds:Breath Sounds:Diminished breath sounds: heard with

poor inspiratory effort and with restricted air flow.

Adventitious breath sounds: respiratory sounds that are heard louder then normal. (Have patient cough to clear secretions.)

CHEST & LUNG ASSESSMENTAbnormal breath sounds (define each):

(reference p. 435)

Crackles

Rhonchi

Wheezes

Pleural Rub

Stridor

CHEST & LUNG ASSESSMENTRespiratory Patters (define each term

(reference table p. 432, 21-3)

Eupnea

Tachypnea

Bradypnea

Kussmaul’s

Chyne Stokes

Apnea


Sequence for anterior auscultation

(p. 436, fig. 21-14A)

Sequence for lateral auscultation

(fig 21-14B)• Sequence for posterior auscultation

(fig. 21-14C)

https://www.youtube.com/watch?v=5JA6D1Mguh0


Cardiovascular assessment:Cardiovascular assessment:



Able to hear heart sounds from any location on the anterior chest.

Point of maximal impulse (PMI): 5th intercostal space (left) & midclavicular line (apex of the heart)



Cardiac auscultation sites (P. 437, fig. 21-15 & 21-16)

Aortic valve: 2nd ICS, R sternal border

Pulmonic valve: 2nd ICS, L sternal border

Tricuspid valve: 4th ICS, L sternal border

Mitral valve: 5th ICS, MCL


Abnormal findings: Abnormal findings:

Murmur: extra sounds produced by turbulent blood flow through the heart.

Causes: incompetent valves, back flow of blood.



Carotid arteries and jugular veins run veins run alongside the sternocleidomastoid alongside the sternocleidomastoid musclemuscle

Carotid pulses: stenosis thrills (palpation) or bruits (auscultation).

Caused by turbulent blood flow.



Jugular vein distention: begin with head of bed flat, vein becomes distended with blood.

As head of bed is raised, distention should decrease. Should disappear at about 30 to 45 degrees.


Cardiovascular assessment:Cardiovascular assessment:Jugular vein distention (JVD):With HOB elevated, the jugular veins are

normally flat & without distention. If distention remains after HOB is

elevated, fluid overload or cardiac failure is indicated. (Poor venous return).



Inspect the periphery for color, temperature, & edema.

Normally the skin is warm, without edema, & with good color.

Pedal pulses (& all pulses) should be regular, strong, & equal bilaterally.


Cardiovascular assessment


Cardiovascular Assessment: Capillary Refill

Purpose: assess tissue perfusion in peripheral parts of the body.

Procedure: press the skin or nail to produce blanching (pale color). Color should return to normal in < 3 seconds.


Cardiovascular Assessment: Peripheral Pulses

Performed to assess the adequacy of peripheral arterial circulation.

Doppler: ultrasonic device

Assess warmth & color of fingers & feet

Abdominal Assessment

Assessed in quadrants or in the nine-region method


Inspection and auscultation of the abdomen are performed before percussion & palpation.

???Can you guess why?????


Inspection:

Normally symmetrical with rounded contour.

Striae: “stretch marks” (silver-white color = old, pink color = new.)

Distention: may be due to gas, bowel obstruction, or fluid retention (ascites)


Auscultation:

Normal bowel sounds are high-pitched, irregular gurgles or clicks lasting one to several seconds and occurring every 5 to 15-30 seconds.


Auscultation:Auscultation:

Absent or hypoactive bowel sounds may occur after abdominal surgery, infection, nerve abnormalities or with bowel obstruction. (< 5 sounds /min)

Hyperactive bowel sounds (Hyperperistalsis: occurring > 5 seconds or > 30/min) may occur with diarrhea, gastroenteritis, or irritable bowels.


Auscultation: Auscultation: for bruits over the aorta, renal, femoral, & iliac arteries are performed by experienced practitioners.

Bruits may indicate an aneurysm, stenosis, or occluded blood flow.


Percussion:Percussion:

Normally: nontender, soft, & without masses.

Tympany: sound heard over bowels filled with gas.

Dullness: sound heard over organs, masses, or fluid collections.


Palpation:Palpation:

Performed by experienced practitioners

Light palpation: to assess for tenderness or guarding.

Deep palpation: to assess organs for masses or tenderness.

The spleen is not normally palpable; when palpable an abnormal etiology is indicated.

The Musculoskeletal System Assessment

Musculoskeletal System Assessment

Includes:

posture

gait

joint mobility

muscle strength

Much of the MS assessment may be part of the nervous system assessment.


Deformities in bone structure affect posture & gait.

The normal four curvatures of the spine should be present.

The head & neck should be at midline


Common abnormalities of the spineCommon abnormalities of the spine:

Kyphosis: accentuated curve of the thoracic spine

Scoliosis: lateral S deviation of the spine

Lordosis: exaggerated lumbar curve

Musculoskeletal System Assessment: Abnormal curvatures of the Spine


Assess spinal curvature by observing the client’s posture while standing erect and having him/her bend forward at the waist while the arms hang free

Normally the cervical & lumber curves are concave; thoracic & sacral curves are convex.


Balance, coordination, & movement Observe walking: base of support &

stride Balance & movement: heel-to-toe &

Romberg test. Coordination: finger-thumb opposition

& heel-shin slide.


Joint Mobility & Muscle Function Normally joints should move freely &

without pain or crepitus Active ROM: independently moves

joint through full ROM. Passive ROM: the joint is moved

through motions by another person.


Muscle strength: Test muscle strength by performing

ROM against resistance (i.e.: push hand away, “step on gas”)

Normal: Active against full resistance Hand-out: Muscle Strength Rating

Scale

Assessing the Neurological System

Work of the nervous system is carried out through the transmission of chemical & electrical impulses and functions to maintain homeostasis.

Much of the neurological assessment is done simultaneously with the musculo-skeletal system.


The CNS controls all of the body’s activities.


Cerebral Function:Cerebral Function:Refers to intellectual, mental, cognitive, &

behavioral function. Level of consciousness (LOC): on

continuum. Glasgow coma scale: (p. 429, tab. 21-2) 3 categories of responses, normal score =

15.

Assessing the Neurological System: Cerebral Function:Cerebral Function:

Orientation level: 4 domains are utilized to describe orientation levels.

1) Time: awareness to time, place & year.2) Place: awareness to surroundings3) Person: recognition of self-identity and

of similar persons. 4) Situation: “Do you know why you are

here?”


Cranial Nerve Function: Cranial Nerve Function: Examples

12 cranial nerves are tested.

I. Olfactory nerve: identify smells

II. Optic nerve: visual acuity

III – VI. Ocular motor function: extraoccular movements are tested.

VIII. Acoustic nerve: hearing & balance


Cranial Nerve Function: Cranial Nerve Function: Examples cont. 12 cranial nerves are testedIX & X: glossopharyngeal & vagus

nerves: observe ability to talk, swallow, & cough.

XII: hypoglossal nerve: can the client articulate sounds and move tongue completely?


Reflex Function: Reflex Function: Automatic responses

Intact sensory & motor pathways are required for normal reflex responses.

Deep Tendon Reflexes (DTR): a slightly stretched muscle tendon is tapped with a rubber percussion hammer

DTR responses are graded:



Common DTR Assessments:

1) Achilles reflex

2) Plantar reflex

3) Brachioradialis reflex

4) Tricepts reflex



Patellar reflex


Reflex Function: Reflex Function: Automatic response

Superficial reflexes: i.e. Babinski response


Sensory Function Assessment:Sensory Function Assessment:Sensory function assessment includes light

touch, light pain, temperature, vibration, position sense, stereognosis, graphesthesia, & two-point discrimination

PT is instructed to keep eyes closed while various stimuli are utilized. The PT is instructed to indicate and describe sensations as they are felt.


Motor & Cerebellar Function: The cerebellum helps to coordinate

muscle movement, regulate muscle tone, & maintain posture & equilibrium.


Disorders of motor & cerebellar function result in pain or problems with movement, gait, or posture.

Assessment of the Male Genitourinary system

Nurse practioners & physicians assess external genitalia and complete comprehensive GU examinations.

Focuses on sexual & reproductive function: requires a straight forward approach to obtaining subjective data.

Assessment of the Male Genitourinary system

The prostate gland is palpated during rectal examination

Assessment of the Female Genitourinary system

Speculum examination: performed to collect specimens and to assess the cervix.

Assessment of the Urinary System

Intake & Output Characteristics of urine Bladder palpation/bladder scan Urine specific gravity (kidneys concentrate urine) Urine & kidney laboratory results

Nursing Assessment

Conclusion

Assessment Closure Activities

Test review activities Read & review key points Review questions page 453-454 Practice skill 21-4 (p.448-449)

head to toe assessments 1) general overview: appearance, posture, grooming, mental state, vs, ht...

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