1. NURS2520 Health Assessment II
Head-to-Toe Assessment

2. Unit One Head-to-toe assessment review

3. Objective One Demonstrate head to toe assessment of the adult client

4. Physical Examination Techniques
Inspection = observation of the client (may at times include use of penlight, otoscope, and/or ophthalmoscope)
Palpation = use of touch to assess client
Use light pressure first to assess body surface
Next use deep palpation to assess underlying structures
Assess areas of pain/tenderness/discomfort last
Percussion = tapping fingers on the client’s skin using short strokes to assess underlying structures to determine size/density/location
Auscultation = use of hearing to assess client

5. Types of Percussion and Auscultation
Direct percussion involves tapping lightly with the pads of the fingers directly on the client’s skin
Indirect percussion involves use of both hands; strike the stationary finger like a hammer to produce the best sound
Auscultation --
Direct auscultation involves listening to the client without using an assistive instrument (i.e. wheezing, chest congestion)
Indirect auscultation involves listening to the client with the use a stethoscope

6. Assessment of 5 Percussion Notes
Flatness = soft intensity, high pitch, short duration
Heard over solid areas (muscle)
Dullness = medium intensity, medium pitch, medium duration
Heard over fluid-filled areas
Resonance = loud intensity, low pitch, long duration
Normal lung sound
Hyper resonance = very loud intensity, lower pitch, longer duration
Heard over hyperinflated areas (emphysema)
Tympany = loud intensity, high pitch
Heard over air-filled areas (gastric air bubble)

7. General Survey
*Begins at first contact with the client and continues throughout the exam
*Provides an overall impression of the client/client system
Appearance and behavior
Appears stated age
Speech/behavior appropriate to developmental stage
Facial expressions
Physical/emotional distress
Skin color
Vision and hearing
Glasses, hearing aid, etc

8. General Survey (cont’d)
Speech
Appropriate, logical
Tone, speed, and clarity
Vocabulary/grammar
Body type and posture
Body size/build
Mobility, gait, and coordination
Physical deformities
Range of motion
Dress, grooming, and hygiene
Poor hygiene/unkempt
Manner of dress appropriate for climate

9. General Survey (cont’d)
Mental status
Level of consciousness
Orientation
Mood, affect
Affect is the emotional state as it appears to others. Mood is the emotional state as described by the patient. Observe the patient's facial expression. No part of the body is as expressive as the face. Feelings of joy, sadness, fear, surprise, anger, and disgust are conveyed by facial expression. Facial expressions generally are not consciously controlled.
Interaction
Vital signs
T/P/R and BP
Pain assessment
Allergies
Height and weight
Nutritional status
Unexplained weight loss

10. Skin Assessment Skin characteristics Temperature Moisture Color
Compare upper and lower extremities, and bilaterally
Excessive warmth may indicate fever, whereas excessive coolness may indicate poor circulation, shock, or hypothyroidism
Moisture
Should be warm and dry (but excessively dry skin may indicate dehydration)
Color
Varies per age, culture, ethnicity
Mongolian spots = blue-black areas that are sometimes present on the lower back or buttocks of African American, Native American, and Asian babies
Capillary hemangiomas (‘stork bites’) = small, irregular pink-red areas present around the face/neck of newborns

11. Common Skin Color Variations
Description
Significance
Pallor
Loss of pink/yellow tones or extreme paleness in light-skinned clients
Loss of red tones in dark-skinned clients
Poor circulation, low hemoglobin level
Assess via oral mucosa, conjunctiva, nail beds, soles of feet, palms of hands
Cyanosis
Blue-gray coloration of the skin; ashen
Central cyanosis is R/T hypoxia
May be seen in extremities after exposure to extreme cold
Jaundice
Yellow-orange cast to the skin
Associated with liver disorders
Assess via sclera, oral mucosa, palms and soles
Flushing
Widespread, diffuse area of redness
Results from fever, excessive room temperature, sunburn, polycythemia, vigorous exercise
Erythema
A reddened area
Associated with rashes, skin infections, prolonged pressure on the skin
Ecchymosis
Bruised (blue-green-yellow) area
Bruising may indicate physical abuse
Petechiae
Tiny, pinpoint red or reddish-purple spots
Extravasation of blood into the skin
May be associated with a disorder or medication

12. Skin Assessment (cont’d)
Skin characteristics (cont’d) --
Texture
Should be smooth and soft
May be affected by exposure, age, endocrine disorder, and impaired circulation
Turgor
Refers to the elasticity of the skin, and indicates hydration status
Skin that takes 3 seconds or longer to return to its original position is termed ‘tenting’, and indicates dehydration
Lesions
Primary = result of disease or irritation
Secondary = develops from primary lesions as a result of continued illness, exposure, injury, or infection
Evaluate for size, shape, pattern, tenderness, pain, etc

13. Skin Nodule--a solid mass extending into the dermis.
(2) Tumor--a solid mass larger than a nodule.
(3) Cyst--an encapsulated fluid-filled mass in the dermis or subcutaneous layer.
(4) Wheal--a relatively reddened, flat, localized collection of fluid. An example is hives.
(5) Vesicle--circumscribed elevation containing serous fluid or blood. An example is chickenpox.
(6) Bulla-- large fluid-filled vesicle. An example is a second-degree burn.
(7) Pustule--a vesicle or bulla filled with pus. An example is acne.

14. Assessing Pitting Edema
Trace
Minimal depression noted when pressure applied +1
Application of pressure creates a depression of about 2 mm; no visible distortion; rapid return of skin to position +2
Application of pressure creates a depression up to 4 mm in depth that disappears in about seconds +3
Application of pressure creates a depression of approximately 6 mm in depth that lasts about 1-2 minutes; area appears swollen +4
Application of pressure creates a depression up to 8 mm in depth that persists for about 2-3 minutes; area is grossly edematous
Skin characteristics (cont’d) --
Edema
Excessive amount of fluid in the tissues
Common in congestive heart failure, kidney disease, peripheral vascular disease, or low albumin levels
Pitting edema is graded on a 0 to +4 scale

15. Assessing the Hair
Assess for color, texture, condition, and distribution
Pediculosis = head lice infestation
Nits (lice eggs) may be found on the hair shaft close to the scalp
Alterations in hair distribution may be the sign of disease
Alopecia = hair loss
Chemotherapy
Nutritional deficiencies
Hirsutism = excess facial or trunk hair
Endocrine disorders
Steroid use
Assess scalp (dandruff, dermatitis, psoriasis, etc)

16. Condition of Nail/Nail Bed Indications or Concerns
Assessing the Nails
Condition of Nail/Nail Bed
Indications or Concerns
Pale or cyanotic beds
Circulatory or respiratory disorders that result in anemia or hypoxia
Half-and-half nails
Appears as a distal band of reddish-pink that covers 20-60% of the nail; caused by low levels of albumin or renal disease
Mee’s lines
Appears as transverse white lines in the nail bed; results from severe illness
Splinter hemorrhages
Small hemorrhages under the nail bed that are associated with bacterial endocarditis or trauma
Black nails
Related to blood under the nail--occurs after a local trauma
White spots
Zinc deficiency
Clubbing
Refers to an angle of the nail bed that is 180° or more (normal is 160°); associated with hypoxic states (i.e. chronic lung disease)
Spooning
Iron deficiency
Thickened nails
Poor circulation or fungal infection
Brittle nails
Hyperthyroidism, malnutrition, calcium and iron deficiency
Soft, boggy nails
Poor oxygenation

17. Vital Signs Body temperature Respirations Blood pressure
Wait for minutes after the client smokes or eats/drinks something hot/cold before taking an oral temperature
Respirations
Count unobtrusively for 30 seconds if respirations are regular, and for 60 seconds if they are irregular
Observe rate, rhythm, and depth of respirations
Blood pressure
Client should be seated with both feet on the floor
Client should be inactive for 5 minutes before measuring
Use correct cuff size, and support the client’s arm at the level of his heart

18. Vital Signs (cont’d) Assess apical pulse Assess radial pulse
Palpate 5th intercostal space at the midclavicular line for stethoscope placement
Count for 60 seconds
Note pulse rate, rhythm, and quality, as well as the S1 and S2 heart sounds
Assess radial pulse
Make sure client is resting while assessing the peripheral pulse
Palpate appropriate site, counting for 30 seconds if the pulse is regular, and for 60 seconds if the pulse is irregular
Compare pulses bilaterally

19. Assessing the Head Observe symmetry of features, facial expressions
Abnormal facial features may indicate genetic or chronic disorder (i.e. Graves’ disease, hypothyroidism/myxedema, Cushing’s syndrome)
Assess jaw motion for clicking, pain, or crepitus, which may indicate temporomandibular joint syndrome (TMJ)
Measure head circumference if indicated
Acromegaly, a disorder of excessive growth hormone, may result in enlarged head in adolescents and adults
Microcephaly is an abnormally small head size that may accompany mental retardation
Hydrocephalus may present in infants and children, indicating an accumulation of excessive cerebrospinal fluid

20. Assessing the Eyes External structures Visual acuity
PERRLA (pupils equal, round, reactive to light and accommodation)
Conjunctiva: smooth, glistening , and ‘peach’ in color
Sclera: smooth, glistening, and blue-white in color
Cornea: transparent, smooth, and moist
Visual acuity
Snellen chart measures distance vision
Myopia = diminished distance vision
Near vision measured by having client read newsprint from a distance of 14 inches
Hyperopia = diminished near vision
Presbyopia = decrease in near vision due to the aging process

21. Assessing the Ears Otic structures
External ear = collects and conveys sound waves; protects the middle ear from the external environment
Otitis externa = infection of the outer ear that may result in a painful auricle or tragus
Middle ear = consists of the tympanic membrane, eustachian tube, and the ossicles; conducts sound waves from the external ear to the inner ear
Otitis media = middle ear infection that may present as tenderness behind the ear
Inner ear = hearing and equilibrium
Cerumen (ear wax) should be present, but should not occlude the ear canal
May be black, dark red, gray, or brown in color

22. Assessing the Nose Sinus areas should be nontender upon palpation
Nasal passages should be pink and moist, and free from drainage or lesions
Septum should be symmetrical
Assess client’s ability to breathe freely through both sides of the nose
Sense of smell is diminished in older adults due to atrophy of olfactory nerve fibers

23. Assessing the Mouth and Neck
Buccal mucosa should be smooth, moist, and pink:
Common Buccal/Oral Variations
Condition of Mouth/Oral Mucosa
Indications or Concerns
Paleness
Anemia or inadequate oxygenation
Canker sores
Painful vesicles that erupt with allergies and stress
Gingivitis
Red, swollen or spongy, bleeding gingiva with receding gum lines; tenderness may be present; this is a sign of periodontal disease
Parotitis
Inflammation of the parotid salivary gland
Stomatitis
Inflammation of the oral mucosa
Leukoplakia
Thick, elevated white patches that do not scrape off; may be precancerous lesions
Thrush
White, curdy patches that scrape off and bleed caused by a fungal infection
Aphthous ulcers
Small, painful vesicles with a reddened periphery and white/pale yellow base; caused by viral infection, stress, or trauma

24. Mouth and Neck Assessment (cont’d)
Mouth/lips should be symmetrical
Assess for swelling or drooping
Assess for difficulty swallowing
Assess teeth for dentures, obvious caries, loose teeth
Tongue should be moist, symmetrical, slightly rough, smooth, pink, and freely movable
Abnormal findings include deviation from midline; glossitis (inflammation of the tongue); limited mobility; dry, furry tongue related to dehydration; black, “hairy” tongue associated with fungal infections; swelling, nodules, or ulcers
Palpate neck for tenderness/nodules, thyroid
Inspect for swelling, ROM

25. Lung Assessment Alterations in respiratory rate
Bradypnea = slow respirations (<10 breaths/minute)
Tachypnea = fast respirations (>24 breaths/minute)
Alterations in respiratory effort
Dyspnea = labored breathing
Orthopnea = inability to breath in the horizontal position
Abnormal breath sounds
Wheezes = high-pitched, continuous musical sounds
Usually heard on expiration
Caused by narrowing of the airways
Rhonchi = low-pitched, continuous sounds
Caused by secretions in the large airways
Often clears with coughing

26. Lung Assessment (cont’d)
Abnormal breath sounds (cont’d) --
Crackles = discontinuous sounds that may be high-pitched, popping sounds (fine crackles), or low-pitched, bubbling sounds (course crackles)
Usually heard on inspiration
Stridor = piercing, high-pitched sound
Primarily heard during inspiration
Indicates respiratory distress
Stertor = labored breathing that produces a snoring sound
Retraction refers to the visible sinking of tissues around and between the ribs, sternum, or clavicles due to respiratory difficulty
Note clubbing, coughing, and signs of hypoxia

27. Cardiovascular Assessment
Observe the precordium (area of the chest over the heart) for pulsations or heaves
Abnormal anywhere except at the 5th ICS MCL (‘point of maximal impulse’, or PMI)
Associated with an enlarged ventricle
Palpate for ‘thrill’ (vibration or pulsation) over the chest
May indicate abnormal blood flow and/or presence of a heart murmur
Assess circulation
Palpate peripheral pulses
Check capillary refill
Assess Homan’s sign or calf tenderness
Assess extremities for peripheral edema

28. Cardiovascular Assessment (cont’d)
Blood pressure
Cuff width should cover approximately 2/3 of the length of the upper arm for an adult, and the entire upper arm for a child
Incorrect cuff size can result in measurement error of up to 30mmHg
Using a cuff that is too large is better than using one that is too small
Use the popliteal artery if brachial arteries unavailable
Systolic pressure may be 20-30mmHG higher in the lower extremities, but diastolic pressure should be the same
Auscultate apical rate and rhythm
Listen to apical pulse for full minute
Compare apical pulse to radial pulses

29. Assessment of the Extremities
Assess for musculoskeletal abnormalities, as major deformities may affect posture and gait
Kyphosis = accentuated thoracic curve
Scoliosis = lateral ‘S’ deviation of the spine
Lordosis = accentuated lumbar curve
Assess balance and movement by having client tandem walking, heel-and-toe walking, deep knee bends, and hopping in place
Assess coordination via finger-thumb opposition and having client run the heel of one foot down the shin of the other
Movements should be smooth and controlled

30. Extremity Assessment (cont’d)
Joints should be smooth, nontender, warm to the touch, and of similar color to surrounding tissue
Color changes may indicate inflammation or infection
Assess effect on joint function
Active ROM
Passive ROM
Crepitus = clicking or grating at the joint
Assess muscle strength by applying resistance while client is performing active range of motion exercises
Should be strong and equal bilaterally
Test ‘hand grasp’ strength and ‘foot push’ strength
Both should be equal bilaterally

31. Assessment of the Genitourinary System
The GI system consists of the external genitalia, rectum, urethra, bladder, kidneys, ureters, and prostate in males
Circumcision = excision of the foreskin of the penis
No longer recommended as routine practice
Parental preference remains widespread
Hernia = protrusion of the intestine or other organ
Typically found in the inguinal area in males
May cause pain and distention
Hemmorrhoids = dilated, painful anal vessels
Commonly seen in pregnancy, childbirth, constipation
Assess for problems or changes in voiding

32. Objective Two Document findings by narrative charting

33. Narrative Charting
Tells the story of the patient’s experience in a chronological format
Goal = track client’s changing health status and progress toward positive outcomes
Especially useful in constructing a timeline of events (i.e. cardiac arrest, etc)
Requires the writing out of the details of the patient’s care in sequence
Be sure to organize your thoughts prior to beginning your documentation, as it can be easy to ramble in narrative charting

34. Unit Two Physical assessment techniques for the lungs and abdomen

35. Objective One Demonstrate the assessment technique of light palpation and percussion to abdomen

36. Examination of the Abdomen
Inspect and auscultate the abdomen first in order to avoid stimulating/altering bowel sounds through percussion/palpation; bladder should be emptied prior to examination
Auscultate bowel sounds in all 4 quadrants of the abdomen
Discontinue NG suction (or clamp tube) if indicated
Absent bowel sounds = no sound auscultated after listening for 5 minutes
Hypoactive bowel sounds = very soft and infrequent (i.e. 1 sound per minute)
Hyperactive bowel sounds = loud, rushing sounds occurring every 2-3 seconds

37. Examination of the Abdomen (cont’d)
Palpation of abdomen
Use light palpation (pads of fingertips) to evaluate for tenderness and guarding, superficial masses
Involuntary rigidity of the abdominal muscles may indicate peritoneal inflammation
Use deep palpation to assess organs (this is an advanced technique that is not usually performed by staff nurses)
Liver border should be smooth and free of masses
Should not be able to palpate the spleen
Abdominal percussion should be primarily tympanic
Liver should be dull over right MCL
Stomach should be tympanic at left lower anterior ribcage
Spleen should be dull near left 10th rib posterior to MAL

38. Objective Two Demonstrate the assessment technique of percussion of the thorax and abdomen

39. Examination of the Thorax
Thorax = formed by the ribs, sternum, and vertebrae; protects the heart, lungs, and great vessels
Assess with client in sitting position
Observe sternal angle
Rib slope should be less than 90°
Estimate chest diameter
Anteroposterior diameter should be twice the size of transverse diameter
‘Barrel chest’ (equal diameters) often seen with COPD
Osteoporosis may shorten length of spine, pushing ribs forward and downward
Light palpation of the lungs (perform both anterior and posterior assessment)
Assess symmetry of respiratory movement by having client inhale deeply while grasping the lateral ribcage with thumbs level to the 10th ribs

40. Examination of the Thorax (cont’d)
Palpation of the lungs (cont’d) --
Assess for tactile fremitus by having client repeat the words ‘99’ while using palm of hand to palpate chest and back
Identify areas of increased or decreased fremitus
Fremitus is decreased (or absent) if the bronchus is obstructed or there is fluid in the pleural space
Fremitus is increased near large bronchi and over consolidated lung tissue (i.e. pneumonia)
Percussion of the lungs
Assess if underlying tissues are air-filled, fluid-filled, or solid
Identify level of diaphragmatic dullness bilaterally during respiration per posterior percussive assessment
Have client fold arm across chest and percuss across the top of each shoulder to identify lung apex
Percuss symmetrical areas of lung while moving down client’s back
Percuss areas along the sides beneath the scapulae and down the middle of client’s back

41. Examination of the Thorax (cont’d)
Percussion of the lungs (cont’d) --
Systematically move down the chest wall for anterior percussion assessment
Should percuss dullness over the heart (left of the sternum from the 3rd to the 5th interspaces)
Dullness replaces resonance when fluid or solid tissue replaces air
Abnormally high dull sounds indicate pleural effusion or atelectasis
Only a large amount of pleural effusion can be detected per anterior percussion because fluid displaces posteriorly when client is in the supine position
Identify upper border of the liver by percussing dullness to the right of the thorax
Identify tympanic gastric air bubble via percussion to the left of the thorax

42. Unit Three Physical assessment techniques for the eye, ear, and nose

43. Objective One Demonstrate the proper use of the ophthalmoscope

47. Examination via Ophthalmoscope
Perform examination in a darkened room
Switch on ophthalmoscope light; turn lens disc to 0
Keep index finger on lens disc to facilitate refocusing during assessment; use right hand when examining client’s right eye, and left hand when examining client’s left eye
Use large round beam (0) for large pupils
Use small round beam for small pupils
Use green/red beam to detect lesions
May use thumb of opposite hand on client’s eyebrow to guide movement, and to gently ‘lift’ upper lid if needed
Have the client look straight ahead at a specific point on the wall; hold scope firmly against your own face with your eye directly behind the sight hole
Hold scope 15 inches away, and about 15˚ lateral to client’s line of vision; shine beam of light on the pupil

48. Ophthalmoscopic Exam (cont’d)
Identify optic disc
Should be yellowish orange, oval or round
Should note branching of vessels away from the optic disc, and progressive enlargement of vessel size as the vessels approach the disc
Disc outline should be clear
Lens should be transparent
Assess for the ‘red reflex’ (orange glow)
Absence may indicate cataract, detached retina, or artificial eye
Keep light beam focused on the red reflex as you move ophthalmoscope closer to the pupil
Identify arterioles and veins
Arterioles are light red, smaller, with bright light reflex
Veins are dark red, larger, with absent light reflex

49. Ophthalmoscopic Exam (cont’d)
Adjust lens disc
Use clear glass lens for normal-sighted client
Use lens with longer focus and rotate lens disc counterclockwise (minus diopters, or red numbers) for nearsighted client
Rotate lens disc clockwise (plus diopters, or black numbers) for farsighted client
Rotate progressively to +10 to +12 diopters to focus on the anterior structures of the eye
Observe macular area (which is responsible for central vision) by having client look directly into the beam
Identify retinal abnormalities
Flame-shaped hemorrhages may indicate hypertension
Large, horizontal line may indicate preretinal hemorrhage
Tiny red spots are indicative of diabetic retinopathy

50. Glaucoma
Cataract

51. Retinal Detachment
Conjunctivitis

52. Stye
Diabetic Retinopathy

53. Objective Two Demonstrate the proper use of the otoscope

56. Otoscopic Examination
Ear Assessment
Perform examination in a darkened room
Use the largest speculum the ear canal can accommodate
Have the client tilt head toward the side not being examined
Pull the helix up and back for adults, and down and back for children under the age of 5
May be painful in clients with acute otitis externa
Insert speculum into outer 3rd of the ear canal; gently manipulate position to visualize the entire drum
Observe for wax build-up, discharge, foreign body, redness or edema
Assess for ‘cone of light’ and bony landmarks (i.e. the ‘handle’ and a portion of the malleus)
Nasal Assessment
Use short, wide nasal speculum
Observe lower portions of the nose, then the upper portions

57. Otoscopic Examination (cont’d)
Assessing the Nose (cont’d) --
Use short, wide nasal speculum
Observe lower portions of the nose, then the upper portions
Assess the nasal mucosa
Should be slightly more red than oral mucosa
Observe for edema, exudates, or bleeding
Inspect the nasal septum for bleeding or deviation (deviated septum is common in clients with chronic allergies, history of broken nose, etc)
Observe the inferior and middle turbinates and middle meatus for edema, exudates, and polyps; note color

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59. Objective Three Assess the anatomical structures visible with the ophthalmoscope/otoscope (*Lab Practice)