Nursing Head to Toe Assessment

Definition of physical examination (Head to Toe Assessment):

A physical examination is the evaluation of a body to determine its state of health.

A complete physical examination (head to toe assessment) usually starts at the head and proceeds all the way to the toes. However, the exact procedure will vary according to the needs of the person being examined and the preferences of the examiner.

Purpose of Physical Examination (Head to Toe Assessment):

• Comprehensive physical examinations (head to toe assessment) provide opportunities for health care professionals to obtain baseline information about individuals that may be useful in the future.
• Allow health care providers to establish relationships before problems occur.
• Physical examinations are appropriate times to answer questions and teach good health practices.
• Detecting and addressing problems in their early stages can have beneficial long-term results.

Procedure of Nursing Head to Toe Assessment:

These are the steps to follow when performing a head to toe assessment as a student nurse.

1. SKIN ASSESSMENT of hands and arms:

Perform the assessment observing the following sequence: inspection, palpation and capillary refill

Inspect skin for:

• Color (redness, pallor, jaundice, and cyanosis).
• Pigmentation (hyper/ hypopigmentation).
• Lesions (note size shape, location, distribution)
• Vascularity and bruising.

Palpate skin for:

• Temperature (cool, warm, hot) using dorsal side of the hand Moisture (dry, sweaty, oily)
• Texture (rough, smooth)
• Thickness of skin with finger pads
• Mobility & skin turgor by pinching up skin over sternum.
• Capillary refill:
• Depress one finger at the time, blanching the nail and waiting for blood return no less than 2 seconds

2. THORAX and LUNG ASSESSMENT

Perform assessment by observing the following sequence: palpation, percussion, auscultation.

Palpate for chest expansion (front or back)

• Back: Place hands on the posterior chest wall with your thumbs at the level of T9 or T 10.
• Pinch up small fold of skin between the thumbs.
• Observe the movement of thumbs by asking the client to take a deep breath

OR

• Front: Place hands over the anterolateral wall
• Place thumbs along the costal margins pointing towards the xyphoid process
• Observe the movement of thumbs by asking the client to take a deep breath

Assess tactile fremitus (front or back)

• Use the palmer base of the fingers or ulnar edge of one hand while client says “ninety-nine”.
• Start at the lung apices and palpate from one side to another
• Assess for symmetry and intensity of vibrations

Percuss the lung field (front or back)

• Start from the lung apices, avoid percussing over the sternum or scapula
• Leave around 5 cm of space between each side
• Compare right with left side checks for the normal resonance sound

Auscultate for breath sounds

• Instruct the patient to breathe through the mouth.
• Use the diaphragm of stethoscope and listen to one full respiration, compare side to side
• Note normal breath sounds to be: bronchial, broncho-vesicular, and vesicular. No abnormal breath sounds

3. ASSESSMENT of HEART and NECK VESSELS

Perform assessment by observing the following sequence: inspection, palpation, percussion, auscultation

Inspect carotid arteries and jugular veins (JV)

• Check for pulsations and distension bilaterally
• Position patient at a 30-40 angle and removes pillows
• Ask patient to turn the head in the other direction
• Check if pulsation or distension of jugular vein or carotid arteries is present

Palpate carotid pulse

• Palpate medial to the sternomastoid muscle in the neck one side at a time
• Palpate gently (to avoid decreasing blood supply to the brain and stimulating the vagal nerve leading to bradycardia and arrest)
• Count for 30 sec X2 or 1 full minute
• Check beats/minute (60-100), rhythm (regular /irregular) force (0= absent, 1+ weak, 2+ normal, 3+ increased, full bounding).

Auscultate carotid arteries

• Keep the neck of the patient in a neutral position.
• Use the bell of the stethoscope at 3 levels on the left and right side
• Avoid compression
• Ask the patient to exhale and hold his/her breath when listening

Auscultate for heart sounds & valves

• Use diaphragm of stethoscope
• Locate proper valve areas where she can best hear the heart sounds as mentioned below.

1- Aortic Valve area- 2nd right Intercostal space

2- Pulmonic valve   – 2nd left intercostal space.

(LUB-DUB/ S1& S2: S2 louder than S1)

3- Tricuspid valve – 4th ICS left lower sternal border

4- Mitral valve     – 5th left intercostal space at midclavicular line

(LUB-DUB/ S1 & S2: S1 louder than S2)

ABDOMINAL ASSESSMENT:

The Nurse performs assessment by observing the following sequence: inspection, auscultation, percussion, palpation

Inspect abdomen and note the following:

• Contour (flat, rounded, protuberant, scaphoid)
• General symmetry- shines a light across abdomen
• Skin: smoothness, color, striae, scars and lesions
• Pulsations (aortic) or movements (peristalsis)
• Umbilicus for discoloration, inflammation, or hernia.
• Patient’s facial expressions and position in bed (Demeanor)

Auscultate for bowel sounds

• Begin in right lower quadrant (RLQ)- ileocecal valve
• Listen in each quadrant (RLQ, RUQ, LUQ, LLQ)
• Describe: character (gurgling, high pitched) and frequency (irregular- 5-30/ minute/ hyperactive or hypoactive or absent)

Palpate the liver span, spleen and right kidney.

Liver span:

• Place a hand on patient’s back (11th -12th rib)
• o Ask patient to inhale and palpate deeply in the RUQ             OR
• Stand at patient’s shoulder
• Hook fingers over costal margin and ask patient to take deep breath

Spleen:

• Place left hand to support the back at 11th & 12th rib
• Place right hand obliquely below the rib margin, pushe hand down deeply

Kidney:

• Palpate right kidney (only)
• Use: “duck-bill” position- Press hands firmly together on flank

Demonstrate light and deep palpation techniques

• Palpate in each of the four quadrants (RLQ, RUQ, LUQ, LLQ)
• Start with light palpation (press 1cm)
• Proceeds with deep palpation (press5-8cm)
• Assess the tenderness, mass, any enlarged organ)

Document the findings of your Head to toe assessment