Nursing Assessment - Head to Toe

Nursing Assessment - Head to Toe

• The physical examination involves observing, palpating, percussing, and auscultating objective anatomical findings.
• The collected information must be integrated with the patient's history and pathophysiology.
• A thorough health history is vital.
• Effective communication with the patient and family is essential.

Purpose of Physical Health Examination

• Collect baseline data on the client's functional abilities.
• Supplement, confirm, or refute data from the nursing history.
• Establish nursing diagnoses and care plans.
• Evaluate the physiological outcomes of health care.
• Assess the progress of a client's health problem.
• Make clinical judgments about a client's health status.
• Identify areas for health promotion and disease prevention.

Nurse's Role in Conducting a Physical Health Assessment

• Perform hand hygiene and introduce oneself.
• Verify the patient's identity (using at least two forms of identification).
• Explain the procedure to the client.
• Obtain informed consent.
• Gather required equipment.
• Respect the client's privacy.
• Position the patient appropriately.
• Maintain confidentiality of data.
• Assist the physician or perform a physical health assessment.
• Clean and replace equipment.
• Document the assessment.
• Ensure client comfort after the assessment.

Introduction (Initial Assessment)

• Knock and introduce self.
• Wash hands.
• Provide privacy.
• Verify patient's name and date of birth.
• Explain what you're doing in simple language.
• While introducing oneself, perform a basic assessment of the patient's overall appearance:
  • Does the patient appear well-groomed?
  • Are there any lesions, masses, or skin breakdown noted?
  • Is there any asymmetry in the body or face?

Components of a Nursing Health History

• Biographical data: Basic patient information.
• Reason for seeking healthcare/Chief Complaint: The patient's main reason for seeking care.
• History of Present Illness (HPI): Use the OLD CART method (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, and Treatment) to gather detailed information about the presenting problem.
• Previous health history
• Family history
• Review of systems
• Lifestyle
• Obstetric history (for women)
• Socio-cultural history
• Occupational and environmental history

Equipment for Conducting Physical Assessment

• Pen and paper
• Marking pen
• Tape measure
• Ruler
• Clean gloves
• Penlight or torch
• Scales
• Equipment for measuring vital signs (thermometer, pulse oximeter, sphygmomanometer)
• Lamp/good lighting
• Tongue depressor
• Stethoscope
• Otoscope

Considerations Prior to Commencing Physical Examination

• Standard precautions
• Transmission-based precautions (if applicable)
• Cultural sensitivity
• Client consent
• Appropriate lighting and accessibility
• Client voiding before examination
• Familiarization with organizational protocols and roles
• Awareness of common health problems

Types of Assessments

• Initial/Baseline: First assessment of a patient, either on admission or during the initial encounter.
• Focused: Assessment of a specific area or areas related to a presenting problem.
• Emergency: Assessment of ABCs (airway, breathing, circulation) in urgent situations to identify the cause of the problem.
• Ongoing/Reassessment: Reassessment of a patient after a period of time or an event to compare findings with baseline assessment.

Techniques of Physical Examination

• Assessment Order: Inspect, palpate, percuss, auscultate.

Components of Physical Assessment

• Vital signs
• Neurological functioning
• Cardiovascular functioning
• Respiratory functioning
• Gastrointestinal functioning
• Genitourinary functioning
• Musculoskeletal functioning
• Pain assessment

General Appearance

• Gender and race: Certain illnesses are more common in specific groups.
• Age: Age affects normal physical characteristics and signs of distress.
• Signs of distress: Look for pain behaviors, difficulty breathing, or anxiety.
• Body type: Slim, muscular, obese, or excessively thin.
• Posture: Slumped, erect, or bent.
• Gait: Observe the walking pattern for coordination.
• General body movements: Note for any tremors involving the extremities, hair, skin, and fingernail appearance.
• Hygiene and grooming: Evaluate the appearance and condition of hair, skin, and nails.
• Affect and mood: Observe emotional state.
• Speech: Observe abnormal pace, which can indicate emotional or neurological issues.
• Substance abuse: Check the history of substance abuse.

Head and Neck Assessment

• Face: Inspect hair, eyes, ears, nose, mouth, temporal artery, sinuses, temporomandibular joint. -Note the general appearance, including skin color. -Overall appearance – Are eyes and ears at the same level? Is the head size appropriate? Is the face symmetrical? -Any facial expressions symmetrical? -Check for any lesions.
• Neck: Inspect the trachea, lymph nodes, and thyroid gland palpates for abnormalities. -Palpate for abnormalities, tenderness, or enlargement.
• Assess for tracheal deviation, this is a medical emergency!.

Eyes, Ears, Nose, and Mouth Assessments

• Eyes: Pupil size, shape, reaction to light and accommodation; Color and condition of the sclera, conjunctiva, eyelid, and eyelids, lashes.

• Ears: Inspect ear position and structure, use penlight to assess the auditory canal for redness, drainage, swelling, or pain.

• Nose and Sinuses: Inspect the nose for shape, color, symmetrical nasal septum alignment. Check for discharge. Inspect the nasal cavity, palpating for tenderness.

• Mouth: Lips, teeth, gums, buccal mucosa, inspect for dental caries, exudates, thrush, and fungal infection

  • Overall appearance
  • Inspection of the palate in the mouth.

Cardiovascular Assessment

• General assessment: Check peripheral circulation - Check if peripheral pulses (peripheral vascular system) are weak, bounding or thready. Check if the peripheries/extremities are cool, warm or hot to the touch.
• Urine output: Assess urine output, a low output could indicate organs aren’t being perfused properly
• Blood pressure: Assess blood pressure.
• ECG: Assess ECG
• Edema: Assess for edema (swelling).
• Capillary refill: Assess capillary refill time.
• Heart rate: Count heart rate for one minute and assess the rhythm
• IV access Check if there is an access present.
• Pain Check for pain in the chest or radiating torso pain.

Respiratory Assessment

• Inspection: Observe breathing rate, rhythm, depth, and effort; note for retractions, use of accessory muscles; assess the chest for asymmetry or deformity, increased anteroposterior diameter; confirm the trachea is near the midline.
• Auscultation: Listen for breath sounds (crackles, wheezes, stridor, rhonchi) in the anterior and posterior chest.

Abdominal Cavity Assessment

• Inspection: Note the general appearance of the abdomen. Note the type and location of pain. Assess for stretch marks, contour, symmetry, and any visible pulsations; note location, contour, and color of the umbilicus; note external signs of injury.
• Auscultation: Auscultate each quadrant to assess for bowel sounds (normal, hypoactive, hyperactive, absent).
• Percussion: Use percussion to assess for dullness or tympany in each quadrant. Identify areas with shifting dullness/tympany as a possible indicator of ascites.
• Palpation: Palpate each quadrant for masses, tenderness, guarding, or pulsations. Assess for crepitus. Avoid palpating an undiagnosed mass.

Genitourinary System Assessment (Male)

• Inspection: Inspect pubic hair distribution (amount, texture, cleanliness) and penis (size, shape, circumcised/uncircumcised), glans, and urinary meatus for abnormalities. Check the scrotum for abnormalities.
• Palpation: Palpate the penis and scrotum for masses or tenderness using your thumb and first two fingers.

Genitourinary System Assessment (Female)

• Inspection: Inspect pubic hair distribution, mons pubis, labia majora, perineum for vascularity and moisture; inspect external genitalia while separating the labia; inspect for abnormalities like swelling, excoriation, or discharge. Inspect labia minora and clitoris. Inspect the size and condition of the vagina, and any ulcers, lesions or swelling. Check for any vaginal discharge, inflammation and any swelling.
• Palpation: Palpate the labia for masses or tenderness. Palpate Bartholin’s glands, urethra, size and condition of the vagina, and skene’s glands. Palpate for femoral and inguinal hernias.

Musculoskeletal Assessment

• Importance: Assess the function and ability to perform activities of daily living (ADLs).
• Questions: Ask the patient if they use any assistive devices (cane, walker, etc.). Ask if they recently had falls. Ask if they need assistance with daily tasks like bathing, dressing, walking, eating, etc.
• Range of Motion (ROM): Assess by observing and palpating for any abnormalities in posture. Assess gait and balance. Note the curvature of the spine. Evaluate any pain related to movement.
• Strength Scale: Assess muscle strength using a 5-point scale.
• Factors affecting physical mobility: Assessing for any conditions, such as nerve degeneration, diabetes, multiple sclerosis, stroke, bone degeneration, medication usage, obesity, or malnutrition.

Skin Assessment

• Inspect: Throughout the assessment, observe the skin for lesions, rashes, discoloration, or any breakdown. Pay attention to any bony prominences, as these are susceptible to breakdown if the patient is malnourished.
• Palpate: Assess skin temperature, texture, moisture, and mobility for turgor, looking for any edema.
• Integumentary assessment: Check skin integrity, evaluate the scalp, hair color, quantity, and distribution, note any odors, and check for edema.
• Clubbed fingers: Check the angle between the nail and skin for clubbing, a sign of chronic tissue hypoxia.
• Types of skin lesions: Evaluate and document any primary or secondary lesions (macules, papules, vesicles, fissures, scales, scars, ulcers, nodules, pustules, plaques).
• Edema grading: Assess pitting or non-pitting edema.
• Skin color variations: Check skin color for pallor (lack of blood flow), jaundice (yellow/orange), erythema (red/pink), and cyanosis (blue). Check mucous membranes as well.
• Skin turgor: Pinch the skin to evaluate turgor – how quickly it returns to normal.

Documentation

• Documentation is a legal record of the client's health status.
• It provides critical information for other healthcare providers.
• Records are usually maintained electronically.
• Accurate and detailed documentation is essential.