Head to Toe Assessment PDF

Nursing Assessment Assessing a Client from Head to Toe INTRODUCTION The physical examination is the process of assessing objective anatomic findings by observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's histo...

Nursing Assessment Assessing a Client from Head to Toe INTRODUCTION The physical examination is the process of assessing objective anatomic findings by observation, palpation, percussion, and auscultation. The information obtained must be thoughtfully integrated with the patient's history and pathophysiology. Therefore, it is the orderly collection of information including health history. Communicate with respect and effective communication with the client and family may PURPOSE OF PHYSICAL HEALTH EXAMINATION To: Obtain baseline data about the client’s functional abilities Supplement, confirm or refute data obtained in the nursing history Obtain data that will help establish nursing diagnoses and plans of care Evaluate the physiological outcomes of health care and thus 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 Knock and Hand hygiene Introduce yourself Verify the patient (2 IDs-Full name, DOB or Full address) Explain the procedure to the client. Get Consent Gather equipment required for physical health assessment. Respect client’s privacy Position the patient Maintain confidentiality of the data NURSE’S ROLE IN CONDUCTING A PHYSICAL HEALTH ASSESSMENT (contd..) Assist the physician or perform a physical health assessment. Clean and replace equipment used. Do documentation. Ensure client’s comfort- post-assessment. COMPONENTS OF A NURSING HEALTH HISTORY Biographic Data- Reason for Seeking Health Care/ Chief Complaint- History of Present Illness- The acronym “OLD CART” could be used to ask questions about the problem. O- Onset L – Location D- Duration C – Characteristic A- Aggravating Factors R – Relieving Factors T – Treatment. COMPONENTS OF A NURSING HEALTH HISTORY Past Health History Family History Review of systems Lifestyle Obstetric history Socio-cultural History Psychological History Occupational and Environment 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 A lamp/good lighting Tongue depressor Stethoscope Otoscope CONSIDERATIONS PRIOR TO COMMENCING PHYSICAL EXAMINATION Standard precaution. Transmission-based precautions. Cultural sensitivity Consent of the client. Appropriate lighting and accessibility to the patient from each side of the bed or chair. Have the client void prior to the examination. During induction and training, may become familiar with organizational protocol and exactly role entails about doing and reporting physical health examination. Be aware of common health problems of a client. TECHNIQUES OF PHYSICAL EXAMINATION COMPONENTS OF PHYSICAL ASSESSMENT Obtain vital signs. Assess:  Neurological functioning  Cardiovascular functioning  Respiratory functioning  Gastrointestinal functioning  Genitourinary functioning  Musculoskeletal functioning.  Pain assessment. General appearance General appearance i. Gender and race: Certain illnesses are more likely to affect the specific gender and race. Eg. Risk of having skin cancer is 20% higher in whites than in blacks ii. Age: Age influences the normal physical characteristics. iii. Signs of distress: There may be obvious signs and symptoms indicating pain, difficulty in breathing or anxiety. General appearance i. Body type: Trim, muscular, obese or excessively thin. ii. Posture: Observe whether the client has a slumped, erect or bent posture. iii. Gait: Observe the walking pattern of the client. Not whether the movements are coordinated or uncoordinated. General appearance (Contd..) vii) Body movements: Note for any tremors involving the extremities. viii) Hygiene and grooming: Note the appearance of hair, skin and finger nails. Also observe for the clothing. ix) Affect and mood: Affect is a person’s feelings as they appear to others. x) Speech: An abnormal pace may be caused by emotions and neurological impairments. xi) Substance abuse: Check for the history of substance abuse. Head and Neck assessment Head and Neck Face: Hair Eyes Neck: Ears Trachea Nose Lymph nodes Mouth © by Lecturio Assessment of head and neck Note general appearance, including skin colour. Head includes- face, hair, eyes, nose, mouth, ears, temporal artery, sinuses, temporomandibular joint. Inspect the face and hair:  Inspect the overall appearance of the face (are the eyes and ears at the same level)?  Is the head an appropriate size for the body?  Is the face symmetrical…. no drooping of the face on one side (eyes or lips). This can happen in Bell’s palsy or stroke.  Are the facial expressions symmetrical (no involuntary movements)?  Any lesions? Hai r Observe the hair color. Assess the quality, and distribution, Assess the scalp thinness for any wounds. of hair. Assess cleanliness. © by Lecturio Palpation Palpate the cranium and inspect the hair for infestations, hair loss, skin breakdown or abnormalities:  Palpate for any masses or indentations  Palpate head for depressions of cranial or facial bones, contusions, haematomas, areas of softness, bony crepitus.  Skin breakdown (especially on the back of the head in immobile patients)?  Inspect the hair for any infestations: lice, alopecia areata (round abrupt balding in patches), nevus on the scalp etc. Hai r Alopeci Infestations Hair shaft abnormalitie a s © by Lecturio Eyes: Color of DischargeInspect eyelids, lashes, and conjunctiva Assess for color, pain, itching, or discharge in: Sclera Eyelids (top and Ducts bottom) Conjunctiv a © by Lecturio  The sclera is the white part of the eye. The palpebral conjunctiva lines the back of the eyelids, while the sclera is the white part of the eye. The bulbar conjunctiva covers the front of the sclera, while Ear: External - Inspect ear position and structure - Use penlight for auditory canal examination Assess external canal for redness, drainage, swelling, or pain. © by Lecturio Nose and Sinus assessment - Inspect nose for shape and color - Check nasal septum alignment-Symmetrical (midline, look at septum for any deviation) - Drainage (ask patient if they are having any discharge) - Use penlight for nasal cavity inspection - Palpate sinuses for tenderness © by Lecturio Palpation Steps to palpate the nose include: Step 1: Gently palpate the external nose if trauma/injury or lesions are present. Use the thumb and the index finger to palpate the contour. Lesions can be palpated with the index finger. Note the consistency of lesions (e.g., are they soft or firm?) (Contd..)  Palpation Steps to palpate the nose (Contd..) Step 2: Palpate the nose for airflow/patency. Occlude one naris at a time while placing your index finger over the outside of the nose/nasal wing. Ask the client to take a deep and quick inhalation in through the nose (like a sniff in which they draw air inwards as if trying to smell something). Note the client’s capacity to breathe inwards. The client should be able to breathe inwards with no obstructions. Steps to palpate the sinuses With your thumb, gently palpate one sinus at a time. Use a circular motion to palpate. Begin with the frontal sinuses inferior to the eyebrows over the bony ridge. Avoid the eye socket. Then, palpate the maxillary sinuses inferior to the zygomatic bone slightly lateral to the nose. Inquire if the client had any pain/tenderness upon palpation. A slight pressure is normal. If pain/tenderness is present, assess further subjectively. Palpation of sinuses Nose: Internal Look into the nasal cavity for swelling, structural deformities, drainage, and color abnormalities. It is important to also assess for nasal patency/obstructio ns affecting the © by airway. Lecturio Mouth: Lips, Teeth, and Mucosa When assessing the mouth, examine: Lips Teeth Gums Buccal mucosa © by Lecturio Mouth: Palate and PharynxPalate Pharynx Inflammation Infection © by Lecturio  Fungal infection of the mouth What is thrush? © by Lecturio Neck assessment General assessment-Neck General assessment of neck includes-lymph nodes, carotid artery, cranial nerves, thyroid gland, trachea Examine neck for stiffness, pain in cervical vertebrae, tracheal deviation, distended neck veins, bleeding, oedema, difficulty swallowing and bruising. Inspect for jugular vein distention Place the patient in supine position at 45-degree angle and have them turn the head to the side and note any enlargement of the jugular vein. Trachea and Lymph Nodes Gently palpate the neck to assess the lymph nodes and trachea. Palpate the lymph Assess the trachea. nodes for inflammation. © by Lecturio  Trachea: Palpation for alignment and position: Unequal space between trachea and sterno-cleido mastoid muscle on each side is abnormal, indicative of trachea displacement.  Palpation (contd..) Palpate thyroid gland from the back: note for nodules, tenderness or enlargement… normally can’t palpate it. Palpate the carotid artery (one side at a time) and grade it (0 to 4+….2+ is normal) Trachea and Lymph Nodes Gently palpate the neck to assess the lymph nodes and trachea Assess the trachea. A deviated trachea is a medical emergency! © by Lecturio Neurological Assessment Neurological System A complete assessment of the neurological system requires time, skill, and attention to detail. Initial assessment should Focused assessment: include: Level of Reflexes consciousness Sensation and Pupils coordination Sensation Cranial nerves Paralysis Sensory evaluation © by Lecturio Neurological System: Level of Consciousness The Glasgow Coma Scale (GCS)is a reliable approachto assess an. Eye Verbal Motor opening response response © by Lecturio Neurological System: Level of Consciousness Point Point Point s s s 1 No eye opening 1 No verbal 1 No motor response Open to response 2 2 2 painful stimuli Incomprehensible Extension to pain Open to verbal 3 3 sounds 3 commands Flexion to Inappropriate 4 Open 4 4 words pain spontaneously 5 5 Withdrawal Confuse from pain 6 d Localizing Oriented pain Obeys Neurological System: Level of Consciousness Open spontaneously Open to verbal 4 3 commands Open to pain 2 No eye opening 1 Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible 2 sounds No verbal response 1 Obeys commands 6 Localizing pain 5 Withdrawal from pain 4 Flexion to pain 3 GCS score: Extension to pain 2 15 No motor response 1  Open spontaneously 4 Mr. Hering is a 49 year-old client Open to verbal 3 commands who experienced loss of Open to pain 2 consciousness and was found earlier in the morning by a No eye opening 1 coworker. Oriented 5 Confused 4 He is lethargic and his eyes are Inappropriate words 3 closed most of the time, but will Incomprehensible 2 open when asked to. sounds No verbal response 1 He is not oriented to time or place, Obeys commands 6 but Localizing pain 5 can follow simple commands when Withdrawal from pain 4 asked Flexion to pain 3 GCS score ? hand. Extension to pain 2 No motor response 1  Open spontaneously 4 Mr. Hering is a 49 year-old client Open to verbal 3 commands who experienced loss of Open to pain 2 consciousness and was found earlier in the morning by a No eye opening 1 coworker. Oriented 5 Confused 4 He is lethargic and his eyes are Inappropriate words 3 closed most of the time, but will Incomprehensible 2 open when asked to. sounds No verbal response 1 He is not oriented to time or place, Obeys commands 6 but Localizing pain 5 can follow simple commands when Withdrawal from pain 4 asked Flexion to pain 3 GCS score: 13 hand. Extension to pain 2 No motor response 1 Types of Paralysis Hemiplegia Paraplegia Quadriplegia Monoplegia © by Lecturio Eyes: PupilsReactivity to light Consensual and nonconsensual response Pupil size 1 2 3 4 5 6 7 8 9 mm mm mm mm mm mm © by mm mm mm Lecturio Neurological System: Pupil Response 1. Dim the lights if possible. 2. Ask the client to look at an object in the distance. 3. Use a penlight to shine light into their eyes from each side. 4. Watch their pupils closely to determine whether or not they constrict in response to light, 5. making note of their size and Remember to compare sides! shape. © by Lecturio Pupil Sizing 1 mm 2 mm 3 mm 4 mm 5 mm 6 mm 7 mm 8 mm 9 mm Pupil Variations Normal sized Pupil reacts to One dilated pupil light (slowly or (compressed cranial briskly) Pupils are equal and nerve III; ominous react normally sign) Bilateral dilated, Pinpoint pupils (pons fixed pupils damage or drugs) (ominous sign, medical emergency) When to Call the Healthcare Provider (HCP) Compare sides Call the HCP if: Pupil size changes from baseline Pupils no longer respond to light © by Lecturio  1 7 4 mm mm mm Which of these are the pupils of a client on opioids?  opioids cause pinpoint pupils. 1 7 4 mm mm mm Which of these are the pupils of a client on opioids? Cardiovascular Assessment General assessment P –Peripheries, Pulses – check if peripheries/ extremities are cool, warm, or hot to touch, check the peripheral pulses to see if they are weak, bounding or thready. U-Urine Output – low urine output (normal = 0.5ml/kg/hour) would indicate that internal organs are not perfused. B- Blood pressure E-ECG, Edema C-Capillary refill - press on skin against bone on sternum for 5 seconds. Then release pressure and count how many seconds it takes for the blanching to disappear. H-Heart rate – count for one minute. Check for rhythm- regular or irregular I-IV access - check if there is an access present and if blood tests were taken for electrolytes P-Pain – check is client is complaining of any chest pain or radiating pain in the trunk. Inspection Cyanosis Chest Symmetry External signs of injury: petechiae, bleeding, cyanosis, bruises, abrasions, lacerations, old scars. Edema Surgical devices - Cardiac Monitoring device, Arterial line Identifying chest deformities Palpation -Vascular System Pulses Jugular vein distention (JVD) Capillary refill Edema © by Lecturio Heart: Palpation of Pulses Carotid artery Palpate pulses that are central and distal. Brachial artery Compare for symmetry in pulsation: Rate Radial artery Femoral Rhythm or artery regularity Tension Popliteal artery Strength or Posterior tibial volume © by Lecturio Jugular Vein Distention Central venous pressure (CVP) and JVD status are indicators of a client’s fluid volume. JVD is a sign of increased CVP and fluid volume overload. Assess for JVD with the head of the bed at Assess the jugular vein for 45°. distention and pulsation. © by Lecturio Vascular System Assessment Capillary refill Cyanosis Cyanosis indicates inadequate Reperfusion should perfusion and oxygenation. occur within 3 This is a medical emergency. © by seconds. Lecturio Vascular System Assessment Pitting or nonpitting edema +1 +2 +3 +4 Pitting edema is assessed and assigned a grade of +1 , +2, +3, or +4. © by Lecturio Auscultation-Heart Sounds First sound The first sound S1 is generated by vibrations created by the closing of the S tricuspid and the mitral valves 1 when the ventricles contract. Tricuspi Close d Close d Mitral d © by Lecturio Heart Sounds Second sound S2 is heard during diastole. Ventricles are relaxing and receive blood from the atria. S 2 The S2 sound is created by Pulmonar y closing of the aortic and pulmonary Aorti valves. c © by Lecturio Critical Cardiovascular Assessment Use the diaphragm of the stethoscope 1. Regularitytoorlisten for: irregularity of the rhythm 2. Heart rate Listen for a full minute for 3. Abnormal heart the apical pulse, especially tones if giving medications like digoxin. © by Lecturio Apical Pulse Apical Pulse Respiratory Assessment Inspection Observe the rate, rhythm, depth and effort of breathing. Listen for obvious abnormal sounds with breathing such as wheezes. Observe for retractions and use of accessory muscles (sternomastoids, abdominals). Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter. Confirm that the trachea is near the midline or not. Accessory muscles used for respiration Palpatio n Identify any areas of tenderness or deformity by palpating the ribs and sternum. Palpation of the anterior and posterior thorax can help identify deformities such as: Asymmetr y Retraction s © by Lecturio Auscultation Use the diaphragm of the stethoscope to auscultate breath sounds. O Posterior Chest O Anterior Chest Sounds you might hear include: O Crackles O Wheezes O Stridor O Rhonchi Abdominal assessment Abdominal Cavity Examination The order of examination is different for the abdominal cavity: Normal order of vs Abdominal order of assessment assessment. 1. 1. Inspect Inspect 2. 2. Palpate Auscultate 3. 3. Percuss Percuss 4. 4. Auscultate Palpate 1. Abdominal Inspection Assess each quadrant for shape, skin abnormalities, masses, movement with respiration, or pulsations. Right upper Left upper quadrant quadrant (RUQ) (LUQ) Right lower Left lower quadrant quadrant (RLQ) (LLQ) © by Lecturio 1. Abdominal Inspection Ensure the bladder is empty before examination Note type and location of pain, rigidity or distension of abdomen. Stretch marks Contour Symmetry Location, contour & color of umbilicus. External signs of injury: bruises, abrasions, lacerations, punctures, old scars. Pulsations Visible peristalsis with abdominal distention can indicate an intestinal obstruction. Ascites and Caput Medusa Ascites: buildup of fluid in the abdomen Caput medusa (snakes): veins that are distended and engorged © by Lecturio  Also check for bleeding on the flanks of the abdomen Periumbilical bruising indicate internal bleeding. © by Lecturio 2. Abdominal Auscultation 3.Abdominal Percussion  4. Abdominal Palpation Do not palpate an undiagnosed mass! Assess each quadrant Pain and for crepitus, tenderness can tenderness, masses, indicate or pulsation. inflammations such as peritonitis Palpate for masses, guarding and © by femoral pulses. Lecturio Genitourinary system Urinary assessment Male genitourinary assessment Male genitourinary assessment ▪Inspect - Pubic hair distribution (amount, texture/ cleanliness/ foreign, body) -Penis (circumcised/uncircumcised)base of penis -Skin and shaft of penis for rashes, lesions, lumps, hardened or tender areas - Glans for size, shape, lesions, or redness and location of urinary meatus, and discharge -Scrotal skin for color, integrity and lesions -Scrotum for size, shape, and position. - With client standing, instructed to bears down, inspected for bulges in inguinal and femoral areas Palpate -Palpate the penis using your thumb and first two fingers. Note any tenderness or nodules. Hernia  Anus & Rectum ▪Inspect - Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium - Sacrococcygeal area for swelling, redness, dimpling, or hair (Contd..)  Anus & Rectum ▪Palpate - External sphincter for tenderness, nodules, and hardness - Rectum for tenderness, irregularities, nodules, and hardness - Prostate for size, shape, tenderness, and consistency - Inspected and described characteristics of stool, if any - Collected and/or tested feces for occult blood, if noted, or needed Female genitourinary assessment  Female genitourinary ▪Inspect - Pubic hair distribution, density, growth. - Mons pubis, labia majora, and perineum for vascularity, moisture, symmetry, lesions, swelling, excoriations, and discharge. - Inspect the external genitalia. Separate the labia and inspect the labia minora, clitoris, urethral orifice and vaginal opening. - Observe for inflammation, discharge, ulceration, varicose veins, swelling and nodules. (Condt…)  Female genitourinary ▪Palpate - Labia (masses, tenderness) -Bartholin's glands, urethra, and skene's glands - Size of vagina, and vaginal musculature - Femoral and inguinal hernia  Anus & Rectum Inspect - Perianal area for lumps, ulcer, lesions, hemorrhoids, rashes, redness, fissures, or thickening of epithelium - Sacrococcygeal area for swelling, redness, dimpling, or hair ▪Palpate - External sphincter for tenderness, nodules, and hardness - Rectum for tenderness, irregularities, nodules, and hardness - Inspected and described characteristics of stool, if any - Collected and/or tested feces for occult blood, if noted, or needed Musculoskeletal system Importance of Musculoskeletal Assessment Range of motion (ROM) Temporal mandibular joint and jaw RANGE OF MOTION: NECK RANGE OF MOTION:WRISTS RANGE OF MOTION: FINGERS RANGE OF MOTION: ELBOW RANGE OF MOTION:SHOUDLERS RANGE OF MOTION:KNEES RANGE OF MOTION:KNEES RANGE OF MOTION:ANKLES Skin assessment Integumentary assessment ▪Inspect -Skin integrity for color variations, lesions, etc. -Scalp -Hair (color, quantity, distribution) -Nails -Note smell/odors -Edema (if appropriate) ▪Palpate -Temperature -Texture and moisture -Mobility and turgor -Edema (if appropriate) Cyanosis Erythema Documenting health and physical assessments findings It is a legal document and a permanent record of the client’s health status. It is a source of client information for other health care providers. The documentation could be electronic or as hard copies. Need to maintain confidentiality. Record the findings as soon as possible after the completion of the health assessment. 2. Abdominal Auscultation Auscultate the types of sounds being heard, along with their frequency and location. Sound: Frequency: Region: Bowel sounds Active RU Q Audible vascular Hypoactive sounds (e.g., LUQ heart beat) Hyperactiv e RLQ Absent LLQ Hyperactive bowel sounds can indicate intestinal obstruction, gastroenteritis while hypoactive or absent sounds can indicate abdominal surgery, peritonitis, or paralytic