✯✯✯ Head To Toe Assessment

Sunday, September 26, 2021 9:58:02 PM

Head To Toe Assessment



Pharmacological Head To Toe Assessment of cardiac disease Head To Toe Assessment include both management of pain symptoms, reducing infarction risks, and Head To Toe Assessment cholesterol in the Photosynthesis Hypothesis. Cannon, C. The examination of sensory Head To Toe Assessment motor reactions Head To Toe Assessment lower and upper extremities reveals no pathologies. Michelle on Head To Toe Assessment 7, at am. Neurological examination revealed no abnormalities. The smooth Head To Toe Assessment are Head To Toe Assessment pink and Head To Toe Assessment while the hard palate has a more irregular texture. Want to get ahead of the game for your first day as a Head To Toe Assessment nurse?

Head to Toe Assessment

Normal Findings Nose in the midline No Discharges. No flaring alae nasi. Both nares are patent. No bone and cartilage deviation noted on palpation. No tenderness noted on palpation. Nasal septum in the mid line and not perforated. The nasal mucosa is pinkish to red in color. Increased redness turbinates are typical of allergy. No tenderness noted on palpation of the paranasal sinuses. Cranial Nerve I Olfactory Nerve To test the adequacy of function of the olfactory nerve: The client is asked to close his eyes and occlude. The examiner places aromatic and easily distinguish nose. Ask the client to identify the odor. Each side is tested separately, ideally with two different substances. Mouth and Oropharynx Lips Inspected for: Symmetry and surface abnormalities.

Color Edema Normal Findings: With visible margin Symmetrical in appearance and movement Pinkish in color No edema Temporomandibular Palpate while the mouth is opened wide and then closed for: Crepitous Deviations Tenderness Normal Findings: Moves smoothly no crepitous. No deviations noted No pain or tenderness on palpation and jaw movement. Gums Inspected for: Color Bleeding Retraction of gums. Normal Findings: Pinkish in color No gum bleeding No receding gums Teeth Inspected for: Number Color Dental carries Dental fillings Alignment and malocclusions 2 teeth in the space for 1, or overlapping teeth.

Tooth loss Breath should also be assessed during the process. Normal Findings: 28 for children and 32 for adults. With or without malocclusions. No halitosis. No lesions noted. No varicosities on ventral surface. Gag reflex is present. Able to move the tongue freely and with strength. Surface of the tongue is rough. Normal Findings: Positioned in the mid line. Pinkish to red in color. No swelling or lesion noted.

Grade 1 — Tonsils behind the pillar. Grade 2 — Between pillar and uvula. Grade 3 — Touching the uvula Grade 4 — In the midline. The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension Normal Findings: The neck is straight. No visible mass or lumps. Symmetrical No jugular venous distension suggestive of cardiac congestion.

The neck is palpated just above the suprasternal note using the thumb and the index finger. Normal Findings: The trachea is palpable. It is positioned in the line and straight. Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements. Describe lymph nodes in terms of size, regularity, consistency, tenderness and fixation to surrounding tissues. Normal Findings: May not be palpable. Maybe normally palpable in thin clients. Non tender if palpable. Firm with smooth rounded surface. Slightly movable. About less than 1 cm in size. The thyroid is initially observed by standing in front of the client and asking the client to swallow.

Palpation of the thyroid can be done either by posterior or anterior approach. Posterior Approach: Let the client sit on a chair while the examiner stands behind him. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the isthmus. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be examined to displace the sternocleidomastoid, while the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined.

Ask the patient to swallow as the procedure is being done. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle, while the index and middle fingers are placed deep to and in front of the muscle. Then the procedure is repeated on the other side. Anterior approach: The examiner stands in front of the client and with the palmar surface of the middle and index fingers palpates below the cricoid cartilage. Ask the client to swallow while palpation is being done. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach.

The client is asked to turn his head slightly to one side and then the other of the lobe to be examined. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined. Again, the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid muscle. Normal Findings: Normally the thyroid is non palpable. Isthmus maybe visible in a thin neck. No nodules are palpable. Check the Range of Movement of the neck. Thorax Cardiovascular System Inspection of the Heart The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts Normal Findings: Pulsation of the apical impulse maybe visible. There should be no lift or heaves. Palpation of the Heart The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex, moving to the left sternal border, and then to the base of the heart.

Normal Findings: No, palpable pulsation over the aortic, pulmonic, and mitral valves. Apical pulsation can be felt on palpation. There should be no noted abnormal heaves, and thrills felt over the apex. Percussion of the Heart The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness. Mitral Valve — Left 5th ICS midclavicular line Positioning the client for auscultation: If the heart sounds are faint or undetectable, try listening to them with the patient seated and learning forward, or lying on his left side, which brings the heart closer to the surface of the chest.

Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem. The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and extra heart sounds. Auscultating the heart: Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral Listen for the S1 and S2 sounds S1 closure of AV valves; S2 closure of semilunar valve. S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve. Listen for abnormal heart sounds e. S3, S4, and Murmurs. Count heart rate at the apical pulse for one full minute.

No abnormal heart sounds is heard e. Cardiac rate ranges from 60 — bpm. Breast Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. The client is seated with her arms on her side. The client is seated with her arms abducted over the head. The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles. The client is seated and is learning over while the examiner assists in supporting and balancing her. While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging, retraction, and fixation. An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion of the suspensory ligaments, to fix, preventing them from upward movement in position 2 and 4.

Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligaments. Normal Findings: The overlying the breast should be even. May or may not be completely symmetrical at rest. The areola is rounded or oval, with same color, Color va,ies form light pink to dark brown depending on race. Nipples are rounded, everted, same size and equal in color. The veins maybe visible but not engorge and prominent. No obvious mass noted. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward.

No retractions or dimpling. Palpation of the Breast Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the periphery to the center going to the nipples. Be sure that the breast is adequately surveyed. Breast examination is best done 1 week post menses. Each areolar areas are carefully palpated to determine the presence of underlying masses. Each nipple is gently compressed to assess for the presence of masses or discharge. Normal Findings: No lumps or masses are palpable. No tenderness upon palpation. No discharges from the nipples. Abdomen In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles.

Inspection of the abdomen Inspect for skin integrity Pigmentation, lesions, striae, scars, veins, and umbilicus. Contour flat, rounded, scapold Distension Respiratory movement. Visible peristalsis. Pulsations Normal Findings: Skin color is uniform, no lesions. Some clients may have striae or scar. No venous engorgement. Contour may be flat, rounded or scapoid Thin clients may have visible peristalsis. Aortic pulsation maybe visible on thin clients. Auscultation of the Abdomen This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion. The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles.

Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum. Peristaltic sounds These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel. Listening to the bowel sounds borborygmi can be facilitated by following these steps: Divide the abdomen in four quadrants.

Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present.

The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 — 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound. Some factors that affect bowel sound: Presence of food in the GI tract. State of digestion. Pathologic conditions of the bowel inflammation, Gangrene, paralytic ileus, peritonitis. Bowel surgery Constipation or Diarrhea. Electrolyte imbalances. Bowel obstruction. Percussion of the abdomen Abdominal percussion is aimed at detecting fluid in the peritoneum ascites , gaseous distension, and masses, and in assessing solid structures within the abdomen.

The direction of abdominal percussion follows the auscultation site at each abdominal guardant. The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness. Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the mid axillary line on the left side. Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.

Percussion of the liver The palms of the left hand are placed over the region of liver dullness. The area is strucked lightly with a fisted right hand. Normally tenderness should not be elicited by this method. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis. Renal Percussion Can be done by either indirect or direct method. Percussion is done over the costovertebral junction. Tenderness elicited by such method suggests renal inflammation. Palpation of the Abdomen Light palpation It is a gentle exploration performed while the client is in supine position.

The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion. This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding. The client is ticklish or guards involuntarily. Presence of subjacent pathologic condition. Normal Findings: No tenderness noted. With smooth and consistent tension. No muscles guarding. Deep Palpation It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall. The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.

Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with this method. In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta. Liver palpation There are two types of bi manual palpation recommended for palpation of the liver. Ask the patient to take 3 normal breaths. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation. An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the abdominal wall.

Ask the client to breath deeply. As the client inspires, the liver maybe felt to slip beneath the examining fingers. Normal Findings: The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt the costal margins. When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender. Extremities Inspection Observe for size, contour, bilateral symmetry, and involuntary movement. Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration. Always compare both extremities. Palpation Feel for evenness of temperature.

Normally it should be even for all the extremities. Tonicity of muscle. Perform range of motion. Test for muscle strength. Please wait while the activity loads. If this activity does not load, try refreshing your browser. Also, this page requires javascript. Please visit using a browser with javascript enabled. If loading fails, click here to try again. Choose the letter of the correct answer. Good luck! Your answers are highlighted below. Question 1. When assessing a clients physical appearance a nurse will note which of the following? Question 2. Question 3. Question 4. When a nurse preforms a corneal reflex test which cranial nerve are they assessing? Question 5. Question 6. Question 7. Question 8. Question 9. Which of the following would not be considered normal findings when assessing the scalp and hair of a middle aged man?

Question A nurse conducting an assesment on a clients head would do what first? What could the nurse assess based solely on the way the client walks into the room? The three things a nurse needs to check for when doing an examination on the eyes regarding the external structures is? When it comes to assessing the clients physical appearance which of the following lists what a nurse would look for? Note any swelling that is present. Feel their radial pulses on both wrists, and note if the pulses are thready, weak, strong, or bounding, and if they are happening at the same time or not.

Check their fingernails for hygiene and nutrition clean, trimmed, smooth, clear and gently press on their fingernails to check for capillary refill. Have you been coughing at all lately? If yes: Is stuff coming up when you cough? If yes: What color is it? Is it thick or thin? Check out this blog post for how to position your stethoscope during a lung assessment. Each time you move your stethoscope to a new place, ask your patient: Please take a deep breath in, and out through your mouth. Listen for a full respiratory cycle at each site. Note their breathing rhythm, effort and depth, as well as if their rib cage is moving symmetrically. Often times they are breathing abnormally because they are aware of their breathing. I like to check their respiratory rate during the cardiac assessment.

Do you need help rolling over? Have your patient roll over, take a listen to their lungs on their backside again, having them breathe in and out through their mouth each time you move your stethoscope. Inspect the skin on their back and bottom. Note if it is red, intact or not, bruised, moist, or anything else you see. You can just relax and breathe normally. Check out this blog post for how to position your stethoscope during a cardiac assessment. Keep their bikini area covered with blankets and pull up their gown enough to see their belly.

Make sure to follow the correct assessment order when doing your abdominal assessment inspect, auscultation, percussion, palpation. Look at their belly first. Then listen with your stethoscope for 15 seconds in each quadrant. Then percuss with your fingers. And lastly, palpate by pressing lightly around their belly. Palpate down their legs. Note if their skin is intact, if there are any bruises or swelling, if their leg hair is patchy or evenly distributed, and if you can see their veins.

Do you get leg cramps? If yes: When do they happen? Is there anything that helps them go away: position changes, walking or sitting, or anything else? Check their toenails for hygiene and nutrition clean, trimmed, smooth, clear and gently press on their toenails to check for capillary refill. Feel their dorsalis pedis pulses at the same time one on each foot and their posterior tibialis pulses at the same time one on each foot. Note if it is thready, weak, strong, or bounding. If no: Alright. I will be back in later. You can use your call light if you need anything sooner. And there you have it! Feel free to use this transcript as you go through your head to toe assessment. I do not have it in PDF form at the moment, but that is a great idea!

Christina, you are my angel friend. Thank you for this valuable information and all your tips! Your graciousness in sharing this information is so appreciated. Sending you a big hug! Keep me updated on how school is going! Great teaching tool. It helps students know what to say, which does not always come naturally. Thank you very much. Thanks Adina! I hope this helps other students, because I know I really struggled at first as a new nursing student. This is awesome! Head to toe assessments for new nursing students and nurses can be intimidating. I will be sharing with other students. Very helpful. Hey there! You will eat, sleep and breathe the nursing assessment.

This is your first test for hearing, and to make sure they can actually hear you I have just a few routine questions I need to ask before we get started. Physical Assessment Alright, thanks for answering all of my questions. This checks for pupil constriction and consensual constriction Now, can you focus on my penlight as I bring it to your nose? Mouth: Can you open your mouth for me please? Nose: Take a look at their nose to check for symmetry.

Do you have a runny nose or are feeling stuffy at all? Palpate around their neck, check for swelling, tenderness, or pain. If yes, ask: Which side? Lungs: Have you been coughing at all lately? Inspect their chest for symmetry and shape, and note the size of their costal angle. Move their gown back up. Is your belly tender at all? Move their gown back down. Do you have any pain or discomfort in your legs or feet right now? Cover their legs back up. Finishing Up: Alrighty, we are all done. Thanks so much for your patience. Is there anything I can get for you?

Lucretia on November 14, at am. I needed this , thank you!!!!! Christina on November 14, at pm. Sarit on November 12, at am. This amazing! Thank you! Do you have this in pdf form?

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