The document outlines a comprehensive head-to-toe assessment procedure for evaluating a patient's health, including inspection, palpation, percussion, and auscultation techniques. It details specific areas to assess, such as posture, vital signs, skin condition, and various body systems including the head, eyes, ears, neck, chest, abdomen, extremities, and back. The assessment emphasizes the importance of patient comfort and communication during the examination process.
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HTT
The document outlines a comprehensive head-to-toe assessment procedure for evaluating a patient's health, including inspection, palpation, percussion, and auscultation techniques. It details specific areas to assess, such as posture, vital signs, skin condition, and various body systems including the head, eyes, ears, neck, chest, abdomen, extremities, and back. The assessment emphasizes the importance of patient comfort and communication during the examination process.
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Head to Toe Assessment ● Their posture (Do they seem to
● Gloves experience problems
● Thermometer sitting/standing?Are they grunting ● Scale during movement?) ● Hight wall ruler ● Is their speech clear or slurred? ● Penlight ● Are there any abnormal smells? ● Stethoscope ● Their alertness (Can they answer ● Blood pressure cuff questions? Are they reluctant to ● Tongue depressor speak?) ● Sterile objects, both soft and sharp ● Signs of distress (Do they seem Inspection visibly confused, pale? Do they have Always performed first. You need to use problems breathing? Are they your sight and smell to check specific body avoiding eye contact?) areas for normal color, shape, and consistency. General Overview Palpation First, you obtain a general overview of the Touching the patient to sense abnormalities patient’s health state. These are the details on (or in) the body is known as palpation; to keep an eye on in this phase of the two kinds of palpation: light and deep. Light assessment. palpation is gentle and gives information about skin texture and moisture, fluids, muscle guarding, and some superficial ● Collect their vital signs. (It’s tenderness the patient may be encouraged to ask permission experiencing. On the other hand, deep before touching a patient. Also, palpation explores the internal structures of explaining what you are doing/what the body to a depth of four to five assessment you are performing will centimeters. help the patient feel more relaxed.) Percussion ● Check heart rate This third technique requires the nurse to ● Measure blood pressure tap on the patient’s body to produce sound ● Take body temperature vibrations. These sounds can confirm the ● Pulse oxymetry presence of air, fluid, and solids. It can also ● Respiratory rate pinpoint organ size, shape, and position. ● Check pain levels Auscultation ● Check hight and weight and The last method of examination is calculate their BMI auscultation. It implies listening to the heart, lungs, neck, or abdomen to gather 2. Hair/ Skin/ Nails information. Direct auscultation is done with the unaided ear. Indirect auscultation Once you have a general overview, you can requires the presence of amplification or start from the top of the body and make mechanical devices, such as a stethoscope. your way down. The assessment is called head to toe for a reason. Some things to From the moment you walk into the room, look out for are: you should start making mental notes of certain physical clues the patient might ● Hair distribution(even/uneven) display: ● Hair infestations (lice, alopecia ● Their general appearance (How areata) does their hygiene, dress, affect seem?) ● Bumps, nits, lesions on the scalp ● Tenderness on scalp ● Tenderness, lumps on the skin ● Assess hypoglossal nerve by asking ● Lesions, bruising, or rashes on skin patient to move tongue from left to ● Temperature, moisture, and skin right texture (is the patient pale, clammy, ● Check the patient’s ability to taste, to dry, cold, hot, flushed?) swallow, and their gag reflex ● Edema ● Consistency, color, and capillary 7. Ears refill of nails ● Pressure areas ● Inspect for drainage or abnormalities ● Test hearing with whisper test 3. Head ● Look inside ear: inspect the tympanic membrane and asses ear ● Shape is rounded, symmetrical discharge ● Upon palpation, no nodules, masses ● Tuning fork tests (Weber’s Test, or depressions are identified Rinne Test) ● Face appears smooth and symmetrical with no nodules or 8. Neck masses present. ● Check neck muscles to be equal in 4. Eyes size ● Palpate lymph nodes ● Check external structures ● Check head movements and ● Assess eye symmetry whether they happen with discomfort ● Check conjunctive and sclera ● Observe neck range of motion. ● Check for PERRLA ● Check trachea placement ● Perform visual acuity test ● Check shoulder shrug with ● Check eyes for drainage resistance ● Check vision with Snellen Chart 9. Chest: Cardiovascular Assessment ● Check six cardinal positions of the gaze ● Listen to the heartbeat. Areas where 5. Nose to auscultate heart sounds: aortic, pulmonic, Erb’s point, Tricuspid, Mitral ● Palpate nose and check symmetry ● Check septum and inside nostrils ● Palpate the carotid and auscultate apical pulse ● Patency of nares (patient can breath through each nostril) 10. Chest: Respiratory Assessment ● Check sense of smell ● Palpate sinuses ● Auscultate lung sounds front and back 6. Mouth and Throat ● Observe chest expansion ● Ask abour efforts to ● Check lips for color and moistness breathe/coughing ● Inspect teeth and gums ● Palpate thorax ● Examine tongue ● ● Inspect the inside of mouth ● Look at tonsils and uvula 11. Abdomen ● Inspect abdomen ● Listen to bowel sounds in all four quadrants ● Palpate all four quadrants of the abdomen to check for pain or tenderness ● Ask about bowel or bladder problems
12. Extremities
● Assess range of motion and strength
in arms, legs, and ankles ● Assess sharp and dull sensation on arms and legs ● Inspect arms and legs for pain, deformity, edema, pressure areas, bruises ● Palpate radial pulses, pedal pulses ● Check capillary refill on fingernails/toenails ● Assess gait ● Assess handgrip strength and equality