1. Conducting a Head-to-Toe Examination Kevin Dobi MS, APRN
Chapter 22
Conducting a
Head-to-Toe Examination
Kevin Dobi MS, APRN
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2. Conducting a Head-to-Toe Assessment
Although you began with knowledge and techniques specific for each system, patient comes to you as a whole person.
You must organize your techniques to examine entire person, literally from “head to toe.”
Begin with head, examine facial characteristics, skin, hair, eyes, ears, mouth, throat, and range of motion of neck in a systematic, organized manner, incorporating neurologic, integumentary, musculoskeletal, visual, and auditory systems within head, neck, nose, and mouth regions.
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3. Conducting a Head-to-Toe Assessment (contd.)
Then you must move on to next region of body and repeat same:
After all body regions examined, document your findings by body system.
Each nurse’s approach to a head-to-toe assessment is unique.
No two nurses do things in exactly same manner, nor are any two patients exactly the same.
As a student, you determine what examination sequence works best for you.
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4. Conducting a Head-to-Toe Assessment (contd.)
It is important to develop a systematic method so that you do not omit any data.
When performing a focused assessment, refer only to those regions needed based on patient’s chief complaint and additional data learned from history.
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5. Performing a Health Assessment
Assessment begins with general survey when first meeting patient:
Observe patient enter room, and note gait, posture, and ease of movement.
Shake hands; note eye contact and firmness of hand grip.
Introduce self; data collection begins by asking patient reason for seeking care.
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6. Performing a Health Assessment (contd.)
Note language spoken and gross hearing and speech capability.
Observe for obvious vision difficulties or blindness and any difficulty standing, sitting, or rising.
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7. Performing a Health Assessment (contd.)
Observe musculoskeletal difficulties:
General affect, interest, and involvement.
Dress and posture.
General mental alertness, orientation, and integration of thought processes.
Obvious shortness of breath or posture that facilitates breathing.
Obesity, emaciation, or malnourishment.
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8. Performing a Health Assessment (contd.)
After initial observations, obtain history, assess vital signs and vision, and prep for examination.
Instruct patient to empty bladder, and collect specimen, if necessary.
Have patient remove clothing, put on gown, and sit on examination table.
Conduct a focused assessment that accommodates patient’s needs.
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9. Performing a Health Assessment (contd.)
Use following sequence only as guide.
Developed to demonstrate how one body system examination is integrated with other body systems to permit a comprehensive regional assessment.
Most important:
Be organized.
Develop a routine; it helps with consistency. SCRIPT
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10. Performing a Health Assessment (contd.)
Before beginning assessment, have clear picture in mind of what you plan to do and in what order.
Practice, practice, practice; learn to become systematic and inclusive.
Imagine yourself as patient, and consider how you would want nurse to be prepared to assess you.
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11. Guidelines for Adult Head-To-Toe Examination
Assessment data collected in general survey during history includes:
Level of consciousness and mental status.
Mood or affect.
Personal hygiene.
Skin color.
Posture and position.
Mobility.
Ability to hear and speak.
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12. Guidelines: Assess Vital Signs and Other Baseline Measurements
Temperature, radial pulse, respirations, and blood pressure (both arms if indicated).
Height, weight, and body mass index.
Visual acuity.
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13. Guidelines: Examine Hands
When taking pulse and blood pressure, inspect skin surface characteristics, temperature, and moisture of hands.
Inspect for symmetry.
Inspect/palpate nails for shape, contour, consistency, color, thickness, cleanliness, and clubbing.
Test capillary refill.
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14. Guidelines: Examine Head and Face
Inspect skull for contour; hair for color and distribution.
If indicated, palpate hair for texture; palpate scalp.
Palpate temporal pulses.
Inspect for facial features and symmetry.
Inspect bony structures of face for size, symmetry, and intactness.
If indicated, ask patient to clench teeth and clench eyes tight, wrinkle forehead, smile, stick out tongue, and puff out cheeks.
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15. Guidelines: Examine Head and Face (contd.)
Inspect bony structures of face for size, symmetry, and intactness.
Evaluate sensitivity of forehead, cheeks, and chin to light touch.
Complete an assessment of cranial nerves.
Inspect skin for color and lesions.
If indicated, palpate skin surfaces, facial bones, and sinus regions; and transilluminate sinuses.
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16. Guidelines: Examine Head and Face (contd.)
Eyes:
Near and peripheral vision.
Inspect eyebrows for hair distribution, underlying skin, and symmetry.
Inspect eyelids and eyelashes for symmetry, position, closure, blinking, and color.
Inspect conjunctiva and sclera for color and clarity; inspect cornea for transparency.
If indicated, inspect anterior chamber.
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17. Guidelines: Examine Head and Face (contd.)
Eyes:
Inspect symmetry of eye movement.
Test extraocular eye movement.
Perform cover-uncover test .
Inspect iris for shape and color.
Assess pupil: Direct and consensual reaction, corneal light reflex, accommodation.
Ophthalmic examination: Inspect red reflex, disc cup margins, vessels, retinal surface, and macula.
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18. Guidelines: Examine Head and Face (contd.)
Ears:
Inspect external ear and auditory canal.
Alignment, position, size, shape, symmetry, skin color, intactness.
Discharge or lesions.
Palpate external ear and mastoid areas for tenderness, edema, or nodules.
If indicated, perform whisper test to evaluate gross hearing.
Perform Rinne’s and Weber’s tests.
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19. Guidelines: Examine Head and Face (contd.)
Ears:
Otoscopic examination: Inspect characteristics of external canal, cerumen, and eardrum (landmarks)
Palpate lymph nodes of head.
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20. Guidelines: Examine Nose, Mouth, and Oropharynx
Assess nasal structure and septum.
Assess nose for patency, symmetry, and discharge.
If indicated, evaluate sense of smell.
Lips, buccal mucosa, and gums for color, symmetry, moisture, and texture.
Assess teeth for number, color, position, alignment, hygiene, and condition.
Assess floor of mouth and hard and soft palates for color and surface characteristics.
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21. Guidelines: Examine Nose, Mouth, and Oropharynx (contd.)
Assess oropharynx for odor, anterior and posterior pillars, uvula, tonsils, and posterior pharynx
If indicated, grade tonsils.
Assess tongue for symmetry, movement, color, and surface characteristics.
If indicated, palpate tongue and gums, evaluate gag reflex, and test temporomandibular joint for movement.
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22. Guidelines: Examine Neck
Observe symmetry and smoothness of neck, trachea, and thyroid.
If indicated, palpate trachea and thyroid.
Inspect neck for range of motion.
If indicated, test range of motion of head and neck; have patient shrug shoulders against resistance.
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23. Guidelines: Examine Neck (contd.)
Palpate carotid pulses (one at a time).
If indicated, auscultate for bruits.
Palpate lymph nodes of the neck.
Observe for jugular venous distention.
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24. Guidelines: Examine Upper Extremities
Inspect patient’s arms for skin characteristics, symmetry, and deformities.
Palpate:
Arms, elbows, and wrists for temperature, tenderness, and deformities.
Brachial or radial pulse for presence and amplitude.
If indicated, epitrochlear lymph nodes.
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25. Guidelines: Examine Upper Extremities (contd.)
If indicated:
Test range of motion, muscle strength, and sensation.
Test and bilaterally compare deep tendon reflexes.
Perform Phalen’s sign or Tinel’s sign to assess for carpal tunnel syndrome.
Test for rotator cuff damage.
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26. Guidelines: Assess Posterior Chest
Nurse moves behind patient; patient is seated—gown to waist for men; gown opened in back for women.
Observe posterior and lateral chest for symmetry of shoulders, muscular development, scapular placement, spine alignment, and posture.
Inspect skin for color, intactness, lesions, and scars.
Palpate vertebrae for alignment and tenderness.
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27. Guidelines: Assess Posterior Chest (contd.)
Observe respiratory movement for excursion, symmetry, depth, and rhythm of respirations.
If indicated, palpate:
Posterior chest and thoracic muscles for tenderness, bulges, and symmetry.
Chest wall for thoracic expansion; posterior chest wall for fremitus.
Down vertebral column for alignment and tenderness.
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28. Guidelines: Assess Posterior Chest (contd.)
If indicated:
Percuss posterior and lateral chest for resonance.
Measure thorax for diaphragmatic excursion.
Percuss costovertebral angle for tenderness.
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29. Guidelines: Assess Posterior Chest (contd.)
Auscultate posterior and lateral chest walls for breath sounds.
If adventitious sounds, assess for:
Bronchophony.
Egophony.
Whispered pectoriloquy.
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30. Guidelines: Assess Anterior Chest
Move to front of patient; patient should lower gown to waist.
Inspect for skin color, intactness, lesions, and scars.
Observe respiratory movement for symmetry, patient’s ease with respirations, and posture.
Observe precordium for pulsations or heaving.
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31. Guidelines: Assess Anterior Chest (contd.)
Palpate left chest wall to for point of maximum impulse (PMI).
If indicated:
Palpate chest wall for fremitus, as with posterior chest.
Percuss anterior chest for resonance.
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32. Guidelines: Assess Anterior Chest (contd.)
Auscultate anterior chest for breath sounds.
Auscultate heart for rate, rhythm, S1/S2 (location, intensity, frequency, timing, and splitting), S3, S4, or murmurs.
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33. Guidelines: Assess Anterior Chest (contd.)
Female breasts:
Inspect for size, symmetry, contour, surface characteristics, and breast or nipple deviation.
Observe for symmetry of breast tissue during movement: Arms over head, behind head, behind back; hands pushed together tightly, patient leaning forward.
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34. Guidelines: Assess Anterior Chest (contd.)
Male breasts:
Inspect for size, symmetry, breast enlargement, nipple discharge, or lesions.
All patients:
Palpate lymph nodes associated with lymphatic drainage of breasts and axillae.
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35. Guidelines: Assess Anterior Chest in Recumbent Position
Elevate patient’s head 45 degrees to inspect for jugular vein pulsations.
If indicated, measure jugular venous pressure for height above sternal angle.
Palpate anterior chest wall for thrills, heaves, and pulsations.
If indicated, measure blood pressure with patient recumbent to compare with earlier reading.
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36. Guidelines: Assess Anterior Chest in Recumbent Position (contd.)
Female breasts:
Provide chest drape for women; expose abdomen from pubis to epigastric region.
Inspect for symmetry, contour, venous pattern, skin color, areolar area (note size, shape, and surface characteristics), and nipples (note direction, size, shape, color, surface characteristics, and discharge).
Palpate breasts; note firmness, tissue qualities, lumps, areas of thickness, or tenderness; areolar and nipple area.
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37. Guidelines: Assess Abdomen
Observe:
Skin characteristics from pubis to midchest for scars, lesions, vascularity, bulges, and navel.
For movement of abdomen, peristalsis, and pulsations.
Inspect abdominal contour.
Auscultate abdomen (all quadrants) for bowel sounds, bruits, and venous hums.
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38. Guidelines: Assess Abdomen (contd.)
Lightly palpate all quadrants for tenderness, guarding, and masses.
If indicated:
Deeply palpate midline epigastric area for aortic pulsation (AP).
Percuss all quadrants and epigastric region for tone.
Percuss upper and lower liver borders, and estimate liver span.
Percuss left midaxillary line for splenic dullness.
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39. Guidelines: Assess Abdomen (contd.)
If indicated, deeply palpate:
Right costal margin for liver border.
Left costal margin for splenic border.
Abdomen for right and left kidneys.
If indicated:
Test abdominal reflexes.
Assess abdomen for fluid.
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40. Guidelines: Assess Abdomen (contd.)
Patient raises head.
Evaluate flexion/strength of abdominal muscles.
Inspect for umbilical hernia.
If indicated, lightly palpate inguinal region for lymph nodes, femoral pulses, and bulges that may be associated with hernia.
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41. Guidelines: Assess Lower Extremities
Patient remains recumbent; abdomen and chest should be draped:
Inspect legs, ankles, and feet for skin characteristics, vascular sufficiency, hair distribution, and deformities.
Palpate lower legs and feet for temperature, pulses, tenderness, and deformities.
If indicated, test range of motion, motor strength, and sensation of hips, legs, ankles, and feet.
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42. Guidelines: Assess Lower Extremities (contd.)
If indicated:
Test for deep tendon reflexes.
Palpate hips for stability and tenderness.
Assess for knee effusion with bulge test or ballottement.
Assess for knee stability with drawer test, McMurray’s test, or Apley’s test.
Assess for hip flexion contracture with Thomas’s test.
Assess nerve root compression with straight-leg raises.
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43. Guidelines: Assess Remaining Neurologic System
Observe patient moving from recumbent to sitting position; note use of muscles, ease of movement, and coordination.
Assess gait: Observe and palpate spine for alignment as patient stands and bends forward to touch toes.
If indicated, evaluate hyperextension, lateral bending, and rotation of upper trunk.
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44. Guidelines: Assess Remaining Neurologic System (contd.)
If indicated:
Test sensory function by using light and deep (dull and sharp) sensation.
Bilaterally test and compare vibratory sensation.
Test proprioception by moving toe up and down.
Test two-point discrimination.
Test stereognosis and graphesthesia.
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45. Guidelines: Assess Remaining Neurologic System (contd.)
If indicated:
Test fine motor functioning and coordination of upper extremities by instructing patient to perform at least two of the following:
Alternate pronation and supination of forearm.
Touch nose with alternating index fingers.
Rapidly alternate finger movements to thumb.
Rapidly move index finger between nose and examiner’s finger.
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46. Guidelines: Assess Remaining Neurologic System (contd.)
If indicated:
Test fine motor functioning and coordination of lower extremities; have patient run heel down tibia of opposite leg.
Evaluate Babinski’s sign and ankle clonus tests.
Test for meningeal signs with Kernig’s and Brudzinski’s signs.
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47. Guidelines: Assess Remaining Neurologic System (contd.)
If indicated, assess cerebellar and motor functions; use at least two of the following:
Romberg’s test (eyes closed).
Walking straight heel-to-toe formation.
Standing on one foot and then other (eyes closed).
Hopping in place on one foot; then other foot.
Knee bends.
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48. Guidelines: Assess Genitalia, Pelvic Region, and Rectum
Male patient is recumbent, adequately draped.
Inspect pubic hair for distribution and general characteristics.
Inspect and palpate penis for color, tenderness, discharge, and general characteristics.
Inspect:
Scrotum for texture and general characteristics.
Sacrococcygeal and perianal areas and anus for surface characteristics.
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49. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
Position patient lying on left side with right hip and knee flexed.
Palpate anal canal and rectum for surface characteristics with lubricated gloved finger.
Note characteristics of stool when gloved finger removed.
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50. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
If indicated, palpate anterior rectal surface for prostate gland size, contour, consistency, mobility, and tenderness.
With patient standing, inspect inguinal canal for bulges.
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51. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
Palpate testes, epididymides, and vas deferens for location, consistency, tenderness, and nodules.
If indicated:
Transilluminate scrotum to assess for fluid and masses.
Palpate inguinal canal to assess for hernias.
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52. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
Female patient should be lying in lithotomy position; examiner should wear gloves.
Inspect pubic hair for distribution.
Inspect and palpate labia majora, labia minora, clitoris, urethral meatus, vaginal introitus, perineum, and anus for surface characteristics.
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53. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
If indicated:
Palpate Skene’s and Bartholin’s glands for surface characteristics.
Inspect and palpate muscle tone for vaginal wall tone, rectal muscle, and urinary incontinence.
Insert vaginal speculum, and inspect surface characteristics of vagina and cervix.
Collect specimen for Papanicolaou (Pap) test and culture.
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54. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
If indicated:
Perform bimanual palpation to assess form, size, and characteristics of vagina, cervix, uterus, and adnexa.
Perform vaginal-rectal examination to assess rectovaginal septum and pouch, surface characteristics, and broad ligament tenderness.
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55. Guidelines: Assess Genitalia, Pelvic Region, and Rectum (contd.)
If indicated:
Perform rectal examination to assess anal sphincter tone and surface characteristics; note characteristics of stool when lubricated gloved finger removed.
Patient resumes seated position; patient should have gown on and be draped across lap.
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56. Question 1
During a complete head-to-toe examination, the nurse will collect data about neurologic functioning by:
Observing the abdominal contour.
Observing breast symmetry.
Auscultating breath sounds.
Observing the patient sit up.
Correct Answer: D
Rationale: Sitting up requires coordination of a number of muscle groups as well as balance.
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