How to Conduct a Head to Toe Assessment
Hello, future nurses! Here’s a step-by-step guide to conducting a thorough head-to-toe assessment. This guide includes helpful tips to establish a routine and boost your confidence while assessing patients. Let’s dive in!
1. Initial Assessment
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The assessment begins the moment you enter the exam room. Take note of:
– General appearance (Hygiene, Dress, Affect)
– Posture (Sitting/standing posture)
– Alertness/orientation
– Signs of distress (Labored breathing, Pallor, Confusion)
– Subjective Data (Medical History, Allergies, Pain)
These initial observations are crucial for evaluating the patient’s mental state. Use this time to gather subjective data from the patient, understanding their reasons for the visit. Ask them about their feelings or the purpose of their visit to the doctor.
2. Vital Signs
After engaging with the patient, seek permission to measure their vital signs. Collecting vital signs is the first physical interaction with the patient during the assessment.
Tip: Always request permission before touching the patient and explain the purpose of each assessment.
3. Hair/Skin/Nails
When examining different body areas (such as abdomen, arms, or legs), note any unusual findings in the skin and hair. Check nails for:
– Delayed capillary refill
– Clubbing
– Fungus
Look out for irregularities like uneven hair distribution, abnormal skin color (Pallor, Cyanosis, Erythema), unusual skin temperature or moisture, reduced skin elasticity, and lesions.
4. Head
– Assess symmetry, size, and shape
– Request a smile and raised eyebrows to assess Facial Nerve
– Palpate the scalp
Watch out for tenderness, swelling, or asymmetry.
5. Neck
– Inspect and palpate lymph nodes and glands
– Have the patient perform neck range of motion
– Check Spinal Accessory Nerve by having the patient shrug their shoulders
Look for tracheal deviation, enlarged thyroid gland, or swollen lymph nodes.
6. Eyes
– Examine external structures
– Use the otoscope to check red reflex
– Assess pupils for PERRLA (Pupils Equal Round Reactive to Light and Accommodation)
– Evaluate extraocular movements to test Oculomotor, Trochlear, and Abducens cranial nerves
– Conduct a Visual Acuity Test for Optic Nerve function
Be alert for discharge, lesions, redness, and abnormal PERRLA responses.
7. Nose and Sinuses
– Test nasal patency by asking the patient to blow through each nostril
– Check olfactory nerve function using scented objects
– Use an otoscope to inspect inside the nose
– Examine the septum’s position
– Palpate sinuses for tenderness
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Look for a deviated septum, nasal polyps, or unusual discharge.
8. Ears
– Inspect the external ear with an otoscope
– Conduct a Whisper Test for hearing assessment (Vestibulocochlear Nerve)
– Note the appearance of the tympanic membrane and cerumen
Notice any discharge, lesions, unusual light reflection on the tympanic membrane, or tympanic membrane scarring.
9. Mouth and Throat
– Examine the oral cavity
– Inspect lips
– Check tonsils and uvula
– Evaluate tongue movement (Hypoglossal Nerve)
– Test taste, swallow ability, and gag reflex (Glossopharyngeal and Vagus Nerves)
Be aware of swelling, asymmetry, lesions, cyanosis, dry/cracked lips, cleft lip, discoloration, dryness, hairy tongue, enlarged tonsils, or cleft palate.
10. Chest (Cardiovascular and Respiratory)
Cardiovascular:
– Palpate and auscultate Apical Pulse
– Listen to heart sounds in different areas
Keep an eye out for pericardial friction rub, murmurs, irregular heartbeat, and S3 or S4 sounds.
Respiratory:
– Compare chest diameters
– Observe chest expansion
– Evaluate breathing effort
– Listen to lung sounds
Note any retractions, labored breathing, asymmetrical chest expansion, gasping, abnormal breathing rates, absent lung sounds, crackles, wheezes, stridor, or pleural friction rub.
11. Abdomen
– Inspect
– Auscultate bowel sounds
– Palpate the abdomen
Look for abnormal pulsations, abnormal bowel sounds, skin discoloration, tenderness, or protrusions.
12. Peripheral Vascular
– Inspect and palpate upper and lower extremities
Pay attention to delayed capillary refill, strong or absent pulses, signs of arterial or venous disease, and skin discolorations.
13. Neurological & Musculoskeletal
– Palpate joints
– Demonstrate Range of Motion
– Assess Deep Tendon Reflexes
Notice any crepitus, swelling, pain, limited motion, hyperactive reflexes, or lack of reflex response.
If tapping triggers a repeated reflex: Test Balance with the Romberg test; Check Gait by observing the patient walk in a straight line.
14. Assessment Conclusion
– Inform the patient when the assessment is complete
– Ask if the patient has any questions or concerns
15. Practice… Practice… Practice
Perfecting your head-to-toe assessment requires practice. During clinical rotations, request permission to assess patients to boost your confidence and skills with different clients.
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Recommended Elsevier Assessment Resources:
– Elsevier Clinical Skills Essentials Collection
– Physical Examination & Health Assessment (Jarvis)
– Mosby’s Assessment Memory NoteCards (2nd Edition)
Now that you’re confident and ready, go out there and conduct thorough patient assessments! You’ve got this!
By Tiffany Lyle
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