Physical
Assessment
Course
Education Team
The sequence for performing a head-to-toe assessment is:
Inspection
Palpation
Percussion
Auscultation
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However, with the abdomen it is changed where auscultation is performed second
instead of last. The order for the abdomen would be:
Inspection
Auscultation
Percussion
Palpation (palpation and percussion are done last to prevent from altering
bowel sounds) 3
Provide privacy, perform hand hygiene, introduce yourself to the patient, and
explain to the patient that you need to conduct a head-to-toe assessment
Identify the patient by looking at the patient’s wrist band.
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In addition, ask the patient where they are, the current date, and current events
(who is the president and vice president) etc.
Collect vital signs: heart rate, blood pressure, temperature, oxygen saturation,
respiratory rate, pain level
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Before even assessing a body system, you are already collecting important information
about the patient. For example:
Looking at the overall appearance of your patient: do they look their age, are they
alert and able to answer your questions promptly or is there a delay?
Does their skin color match their ethnicity; does the skin appear dry or sweaty?
Is their speech clear (not slurred)?
Do they easily get out of breath while talking to you (coughing etc.)? 6
Before even assessing a body system, you are already collecting important information
about the patient. For example:
Any noted abnormalities?
How is their emotion status (calm, agitated, stressed, crying, flat affect, drowsy)?
Can they hear you well (or do you have to repeat questions a lot)?
Normal posture?
Abnormal smells?
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How is their hygiene?
Assess height and weight and calculate the patient’s BMI (body mass index).
Below 18.5 = Underweight
18.5-24.9 = Normal weight
25.0-29.9 = Overweight
30.0 or Higher = Obese
BMI = Kg/m2
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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? 9
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Palpate the cranium & inspect hair for infestations, hair loss, skin breakdown or abnormalities:
Palpate for any masses or indentations
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.
Palpate the temporal artery bilaterally 11
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Palpate the temporomandibular joint
for grating or clicking: Have the patient open and close the
mouth and feel for any grating sensation or clicking.
Palpate the frontal and maxillary sinuses for tenderness:
patient will pressure but should not feel pain
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Anterior fontanel: should close within 2-3 months of birth.
Posterior fontanel: should close within12-18 months of birth.
Both fontanels should be flat
Depressed fontanels indicate dehydration.
Bulged fontanels indicate increased ICP
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Inspect the eyes, eye lids, pupils, sclera, and conjunctiva
Is there swelling of the eye lids?
Is the sclera white and shiny?…not yellow as in jaundice
Is the conjunctiva pink NOT red and swollen?
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Look for Strabismus and Aniscoria:
Strabismus: Do the eyes line up with another?
Aniscoria: Are the pupils equal in size…or is one pupil
larger than the other?
Are the pupils clear…not cloudy?
Normal pupil size should be 3-5mm in usual light, 2 to 4
mm in bright light and 4-8 mm in darkness and equal 19
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Reactive to light?
Dim the lights and have the patient look at a distant object (this dilates the pupils)
Shine the light in from the side in each eye.
Note the pupil response: The eye with the light shining in it should constrict (note the
dilatation size and response size (ex: pupil size goes from 3 to 1 mm) and the other
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side should constrict as well.
Accommodation?
Make the lights normal and have patient look at a distant object to dilate pupils, and
then have patient stare at pen light and slowly move it closer to the patient’s nose.
Watch the pupil response: The pupils should constrict and equally move to cross.
If all these findings are normal you can document PERRLA.
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Pupils – Equal – Round – Reactive – Light - Accommodation
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Medications (Antihistamines, Decongestants, Tricyclic antidepressants, Motion sickness
medicines, Anti-nausea medicines, Anti-seizure drugs, Medications for Parkinson's
disease, Botox and other medications containing botulinum toxin, Atropine)
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Eye injury
Brain injury or disease
Sexual attraction
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Antihypertensives
Narcotics
Heroin
Pesticides
Head injury
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Inspect the ears for:
Drainage (ear wax) or abnormalities
Ask the patient if they are experiencing any tenderness and palpate the pinna and targus.
Palpate the mastoid process for swelling or tenderness.
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Inspect the tympanic membrane:
Use an otoscope to look at the tympanic membrane. It should appear as a pearly
gray, translucent color and be shiny. Remember for an adult: pull up and
back and for a child down and back on the pinna.
Also, the cone of light should be at the 5:00 position in the right ear and 7:00
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position in the left ear.
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Inspect nose
Symmetrical (midline, look at septum for any deviation)
Drainage (ask patient if they are having any discharge)
Use a penlight to shine inside the nose and look for any lesions, redness, or polyps
Then have the patient close one nostril and have the patient breathe out of it and do
the same for the other…are they patent?
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Inspect lips (lip should be pink NOT dusky or blue/cyanotic or cracked, and free from lesions)
Inspect the inside of the mouth:
Color of mucous membranes and gums should be pink and shiny. The teeth should be white
and free from cavities. Note: any broken or loose teeth too.
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Inspect lips (lip should be pink NOT dusky or blue/cyanotic or cracked, and free from lesions)
Inspect the inside of the mouth:
Color of mucous membranes and gums should be pink and shiny. The teeth should be white
and free from cavities. Note: any broken or loose teeth too.
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Inspect the trachea
Is it midline, are there any lesions, lumps (goiter), or enlarged lymph nodes (have
patient extend the neck up so you can access it better)?
Inspect for jugular vein distention
Place the patient in supine positon at 45 degree angle and have them turn the head
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to the side and note any enlargement of the jugular vein.
Palpate the lymph nodes with the pads of fingers and feel for lumps, hard nodules,
or tenderness: Preauricular, postauricular, occipital, parotid, jugulodiagastric (tonsillar),
submandibular, submental, superficial cervical, deep cervical chain, posterior cervical,
supravclavicular
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Palpate the trachea and confirm it is midline
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)
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Inspect arms and hands
Deformities? (Heberden or Bouchard nodes as in osteoarthritis on fingers)
Any wounds or IVs or central lines? (Assess for redness or drainage,
expiration date etc.),
Hand and fingernails for color: they should be pink and capillary refill
should be less than 2 seconds 39
Inspect arms and hands
Inspect joints for swelling or redness (rheumatoid arthritis or gout)
Skin turgor (tenting)
Palpate joints (elbows, wrist, and hands) for redness and move the
joints (note any decreased range of motion or crepitus)
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Palpate skin temperature
Palpate radial artery BILATERALLY and grade it. If the patient receives dialysis
and has an AV fistula, confirm it has a thrill present.
Assess for arm drift by having the patient close their eyes and
extend both arms for ten seconds. Note any drifting.
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Inspect the chest
Is the respiratory effort easy? Is the patient using the
abdominal or accessory muscles for breathing?
Assess the skin for wounds, pacemaker present,
subcutaneous port etc.?
Heart Sounds:
Auscultate heart sounds at 5 locations, specifically valve
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locations:
Lung Sounds
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Switching to Inspection, Auscultation, Percussion, and Palpation
Have patient lay supine
Inspect:
Stomach contour scaphoid, flat, rounded, protuberant?
Noted pulsations at the aorta (noted in thin patients): The aortic pulsation can be
noted above the umbilicus.
Characteristics of the navel (invert or everted)
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Masses (check for hernia after auscultation)
Auscultate with the diaphragm for bowel sounds:
start in the RIGHT LOWER QUADRANT and go clockwise
in all the 4 quadrants
should hear 5 to 30 sounds per minute…if no, bowel sounds
are noted listen for 5 full minutes
Documents as: normal, hyperactive, or hypoactive
Femoral arteries: found in the right and left groin. 45
Auscultate for bruits (vascular sounds) at the following
locations using the BELL of the stethoscope:
Aorta: slightly below the xiphoid process midline with
the umbilicus
Femoral arteries: found in the right and left groin.
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Purpose: to evaluate internal organs and identify any sources of pain (if present)
Prior to palpation, ask the patient whether they have abdominal pain or tenderness.
If so, begin palpation in the non-painful area.
Observe the patient's face during abdominal palpation
as it is the main indicator of the intensity and location of pain.
Procedure:
Superficial palpation: to assess for superficial or abdominal wall processes 47
Assess for:
Rebound tenderness: abrupt increase in pain when an examiner suddenly releases
compression of the abdominal wall. Caused by irritation of the receptors in
peritoneum or appendicitis.
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Assess for:
Abdominal guarding: patient contraction of the abdominal wall muscles during palpation
Involuntary guarding ("rigidity"): involuntary tightening of the muscles due to
peritoneal inflammation and is often localized to a specific abdominal quadrant.
Voluntary guarding: voluntary contraction in order to avoid pain during the
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examination and is often generalized over the entire abdomen.
Palpation of the liver
Place the pads of your fingers over the right upper quadrant, approx. 10 cm below the costal
margin at the mid-clavicular line. Palpate as you move towards the right upper quadrant
and attempt to feel for the edge of the liver.
Continue until you feel the liver or reach the costal margin.
Asking the patient to take a deep breath may facilitate palpation of the liver, as the movement
of the diaphragm will move the liver toward your hand. 50
Palpation of the spleen
Place the pads of your fingers lateral to the belly button and palpate as you move
towards the left upper quadrant. Repeat 10 cm below the left costal margin.
Asking the patient to lie on their right side may facilitate palpation of an enlarged
spleen.
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Check for hernia: have patient raise up a bit and look for hernia
Palpation of the abdomen:
Light palpation (2 cm): should feel soft with no pain or rigidity
Deep palpation (4-5 cm): feel for any masses, lumps, tenderness
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Place the middle finger of your non-dominant hand against the abdominal wall. With the tip
of the middle finger of your dominant hand, strike the distal interphalangeal joint 2–3 times.
If there is distension with dull sound it way be due to constipation or ascites.
If there is distension with resonant sound it way be due to gaseous distension.
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Inspect:
color from legs to toes?
normal hair growth? (peripheral vascular disease: leg may be hairless, shiny, thin)
warm (good blood flow)?
swelling (press down firmly over the tibia…does it pit?)
any redness, swelling DVT (deep vein thrombosis)?
capillary refill less than 2 seconds in toes?
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Inspect:
How do the toe nails look (fungal or normal)?
Sores on the feet (Note: with diabetics, foot care is important. They don’t have good sensation
on their feet. Therefore, inspect the feet for damage because they may not be aware of it.)
Is there any breakdown on the heels?
Assess joints of the toes and knees (any crepitus, redness, swelling, pain)
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Inspect:
color from legs to toes?
normal hair growth? (peripheral vascular disease: leg may be hairless, shiny, thin)
warm (good blood flow)?
swelling (press down firmly over the tibia…does it pit?)
any redness, swelling DVT (deep vein thrombosis)?
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capillary refill less than 2 seconds in toes?
Inspect:
How do the toe nails look (fungal or normal)?
Sores on the feet (Note: with diabetics, foot care is important. They don’t have good sensation on
their feet. Therefore, inspect the feet for damage because they may not be aware of it.)
Is there any breakdown on the heels?
Assess joints of the toes and knees (any crepitus, redness, swelling, pain)
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Palpate pulses bilaterally: popliteal (behind the knee), dorsalis pedis (top of foot),
posterior tibial (at the ankle) and grade them
Palpate muscle strength: have patient push against resistance with feet and lift legs
Test Babinski reflex: curling toes is a negative normal response
Turn patient over and look at back (could listen to lung sounds if haven’t already) look
for skin breakdown on back and bottom and abnormal moles 60
Sites:
Over the dorsum of the foot
Behind the medial malleolus
Lower calf above the medial malleolus
Dorsum of hand palm
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Types: pitting, non pitting
Grades:
Grade 0: No clinical edema
Grade 1: Slight pitting (2 mm depth), rebounds immediately.
Grade 2: Somewhat deeper pit (4 mm), rebounds in< 15 seconds.
Grade 3: Noticeably deep pit (6 mm), rebounds in< 30 seconds.
Grade 4: Very deep pit (8 mm), rebounds in> 30 seconds.
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