Head to Toe Assessment

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Author:
mommy2pj
ID:
93599
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Head to Toe Assessment
Updated:
2011-07-11 00:28:27
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head toe assessment
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Head to Toe Assessment
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  1. Head
    • General Appearance: size, shape, skin color, distribution of hair
    • Face: expression, rash, lesion, symetry, Cranial Nerve 7 (smile, raise eyebrows, puff out cheeks, close eyes tight), Cranial Nerve 5 (close eyes,- pt name location of touch)
    • Palpate: temporal artery (between top of ear and eye) normal finding-> nontender (ask) and elastic
  2. Eyes
    • General Appearance: external eye, eye lash, eyelid, position of eye
    • PERRLA: pupil equal, round, reactive to light and accomodation (shine light pupil should constrict), (accomodate- focus object at distance bring close to face, pupil should constrict)

  3. Ears
    • General Appearance: lumps, smooth skin, color as face, lesion
    • Palpate: external ear, mastoid process for tender, ask if hearing change
  4. Nose
    • General Appearance: color, shape, consistancy
    • Palpate: for tenderness (nose/sinus), check patency of nostril (hold one nostril then other), ask if any smell change
    • Internal nose: transluminate PRN (shine light look for fld/secretions
  5. Mouth/ Throat
    • (use gloves, tongue depress, pen light),
    • General Appearance: lips (color, consistancy, lesion), teeth( note #, condition), gums ( color, consistency, lesion), uvula (say "ah" use light is there a rise?) any taste change?
    • cranial nerve 9/10: test gag reflex, (use tongue depress/pt open mouth)
  6. Neck
    • General Appearance: swell, tender, lesion, symetry, mass, harness
    • ROM: head turn L/R, chin to shoulder, ear to shoulder, chin to chest, look up (smooth/controlled?)
    • Palpate: lymph nodes in front/behind ear(hard, tender, swell)
    • trachea: finger in sternal notch
    • thyroid gland: index finger/thumb around throat (not palpable)
    • Carotid artery: 1 at a time, (auscultate with bell) pt hold breath each side. normal-> no swish/blow
  7. Arms
    • general appearance: skin color, lesion, texture, moisture, mass, swell
    • ROM: arms together, up, behind head, elbow to head, arms out, palm up/down
    • palpate: brachial, radial, ulnar pulse
    • ROM wrist: hand up/down
    • muscle strength: pt push against hands
    • palpate palm: temp
    • capillary refill: <3 sec/note color of nail bed
    • ROM finger: finger out/fist, up/down
    • Movement of hands: palm up/down start slow then fast (control vs uncontrol?)
    • sensation of hand: pt close eyes, where are you touching?
    • sensitive of postion: pt close eyes, direction you are moving fingers
  8. Thorax (posterior/lateral)
    • general inspection: tender, mass, leasion, shape, spine abnormal, ask if SOB/diff cough?
    • crepitis: palpate for air in tissue (crackles)
    • fremitis: "99" as move hands down
    • chest expansion: (T9/T10) hand around chest thumbs move 5-10 CM as breathes
    • percuss: for tone-tap finger across top and down in zig zag
    • auscultate: breath sound/adventicious (wheeze, crackle, pleural friction rub)
  9. Thorax (Anterior)
    • general appearance: diameter of chest, slope of rib, skin color, barrel chest, intercostal space (bulge, retraction, use of accessory muscle)
    • quality/pattern of breath: note rate, depth, rythem
    • palpate: tender, sensation, lesion, mass, fremitis ("99")
    • percuss: for tone, start at clavicle
    • auscultate: chest sound/adventicious (5 places bilateral)
    • skin turgor: under scapula
    • breast exam: palpate breast tissue/axilla
  10. Heart
    • Appearance: visual pulsation, palpate pulsations, apical pulse (palm of hand find pulse use 1-2 finger pad)
    • Auscultate:
    • aortic: R side, 2nd intercostal/R sternal border
    • pulmonic: (S2 Dub)-L side, 2nd intercostal/L sternal border
    • Erbs: L side, 3rd intercostal/ L sternal border
    • Tricuspid: L side, 5th intercostal/L sternal border
    • Mitral: (S1 Lub)-L side, 5th intercostal/Medial to clavical midline
  11. Abdomen:
    • appearance: visual pulsation, skin color, straia, lesion, mass, vascularity, rash, scar, mole, distention, umbilicus(location, contour, color)
    • symmetry/contour: flat/evenly round, parastalsys waves or aortic pulsation visible? )
    • auscultate bowel sounds : 4 quadrants (5-30/min) frequency, intensity, pitch
    • vascular sound:
    • aorta: above umbilicus
    • renal artery: bilateral umbilicus
    • iliac artery: bilateral below umbilicus
    • femoral artery: bilateral groin/leg
    • percuss: tone (4 quadrant) tympany over stomach/dull over other organs
    • palpate: mass, large organ, tender
  12. Leg / feet / toes
    • appearance: skin color, texture, moisture, edema, hair distribute
    • ROM: hips, (leg up and bring to chest)
    • Palpate:
    • femoral pulse,
    • popliteal pulse (bend knee, thumb on top, fingers deep in bend of knee)
    • dorsalis pedis (ankle, inside big toe/top of foot)
    • Posterial tibial (in groove between ankle and achiles tendon)
    • ROM: feet up/down, out, in, toes up/down
    • capillary refill: <3 sec
    • sensitive to position: eye closed, which direction move toes
    • sensation to touch: close eyes, where are you touching?

  13. Musculoskeletal / Neuro
    • Heel shin Test: L heel move down R shin, R heel move down L shin
    • Petella reflex: Knee hit/kick
    • spinal curvature: stand, lean forward and look at spine
    • walk around room:
    • rhomberg test:
    • feet together, arms at side, close eyes
    • open eyes, arms out to side, take R index finger touch nose/L index finger touch nose
    • repeat with eyes shut
  14. mixing insulin
    • roll cloudy
    • draw up amt of air for cloudy insulin
    • inject air into cloudy
    • draw up amt of air for clear insulin
    • inject air in clear insulin and withdrawl insulin from clear
    • insert needle into cloudy insulin and withdrawl amount per order

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