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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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0% found this document useful (0 votes)
17 views3 pages

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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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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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

13. Back area

● Inspect back and spine


● Inspect coccyx/buttocks

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