Head To Toe Assessment – Guide & Documentation Cheat Sheet For Head To Toe Assessment

Nursing assessment is always been the most important and crucial thing in a nursing process.

Correct assessment by a nurse leads to the correct evaluation of a patients suffering and ends in correct nursing diagnosis.

‘Head To Toe Assessment’ plays an important part in nursing diagnosis.

Here is the few cheat sheets for you to help yourself.

Head toe assessment

Head to toe is the basic part of every clinical examination. And it is important for every nurse  as well as doctors.

It covers all the part of body from head to toe & not only related to physical body parts but also include mental makeup of patient.

This assessment should be done for every new case. Also ask the question to patients as per need.

Before heading to learn head to toe assessment in detail please check out this video for visual understanding.

 

Instruments required for head to toe assessment

  • Sphygmomanometer
  • Stethoscope
  • Thermometer
  • Pulse Oximeter
  • Small torch

This assessment start by examining the vital signs of patient,  that is Temperature , pulse, Blood pressure , Respiration, O2 level etc.

Temperature

Check the temperature in degree Celsius with thermometer to rule out the fever

Pulse

It measured in beats per minutes by palpable method.

Generally pulse measured on radial artery located at wrist on lateral side of distal forearm.

Blood pressure

It is defined as the lateral pressure exerted by blood on vessel wall & measured by the instrument called Sphygmomanometer.

When it comes to blood pressure measurement, there are two type of it –

  1. Systolic pressure
  2. Diastolic pressure

Systolic is highest reading when heart throws blood by its pumping action to the peripheral artery.

Diastolic is lowest reading on instrument shows blood return to the heart through veins.

Respiration

Examination of respiration includes watching for normal chest movement, respiration rates, also difficulty in breathing or not.

Once you finish with vital signs, you can start physical examination starting from head.

Head (scalp, hair, skull)

It includes observation of shape & size of head. Look for injury, scar if any. Normally skull is round with no tenderness. See if you found any nodule or mass.

Observe hair for alopecia dandruff

Face

Observe for any abnormality including scar, injury, pigmentation etc. Watch for shape of face or there is any swelling or not.

Check for movement of chicks to rule out facial palsy. Ask patient to smile & check the movement of both chicks. Generally movement of both chicks are equal

Eyes (eyebrows, eyelashes, vision)

Generally eyebrows are in one line with each other & colour may depend on race

Eyelashes should be also equally distributed and curled outward. Colour depend on race

To check movement of both eyelids and eyelid muscles you can ask them to look down slowly.

Sclera

This part is easily seen on examination of patient. Generally it includes examination of colour of sclera which is normally white in colour.

See if there is Yellow discoloration of sclera or not. Yellow colour of sclera is a sign of icterus.

 Cornea and conjunctive

Normally cornea is smooth and transparent and no irregularities found. It should be examined by using penlight & holding it in an oblique angle with eye. Then move the penlight slowly across eye.

Conjunctiva is pinkish-reddish in colours with no ulcer

Pupil

Pupil is most important part of an eyes examination. The observation of pupil includes size shape and reaction to light

Normally pupils are round & constrict to direct focus of light. They also constrict on near object and dilate on distant object

Ear

It includes the observation for size, shape, colour of skin, injury or scar mark if any .

Also observe the inner canal of ear for discharges, foreign particles. Observe for size and shape of pinna, auricles, and ear lobes

Normally colour is same as complexion

Nose

Observation includes displacement of bone and cartilage, which is known as deviated nasal septum, movement of alae nasi, any discharge from nose , any tenderness or mass etc.

Normally there is no discharge no deviated nasal septum . Nose is on midline with no wide movement of alae nasi

Mouth (with lips)

General observation is for symmetry, colour & swelling. Normally there is no swelling or oedema lips are in line with pinkish line

Teeth, Gums, Tongue

General observation for teeth is colour, number of teeth carries if any.

Gums observation for swelling, bleeding, colour etc.

Tongue observation for movement, test buds, surface of tongue. Normally tongue is pinkish in colour with no baldness, taste bud presents.

Tonsils

This is most basic part in examination of mouth. Generally observation includes swelling, size of tonsils. Swelling of Tonsil causes throat pain in patient and difficulty in swallowing may be associated with fever.

Neck

It includes observation for any mass lump, position of thyroid glands, jugular vein. Normally there is no lump or mass, no jugular vein distension, not major palpable thyroid glands. Neck is straight with normal movement.

Thoracic region

(Cardiovascular system)

Generally auscultation is done for heart sound.

General anatomical areas for auscultation of heart sound –

Aortic valve – Right second intercostal space along sternal border

Pulmonic valve – Left second intercostal space along sternal border

Tricuspid valve – Left fourth intercostal space along sternal border

Mitral valve – Left fifth intercostal space along midclavicular line

Also see for the shape, size, movement of chest, Tenderness, mass or lump on chest

 

Breast (in female)

Examination of breast must be done to examine tenderness, mass or lump in breast if any.

Areola & nipple should be checked.  See if nipples are retracted or not. (Normally they are not retracted.)

Normally there is no tenderness, mass or lumps in breast. Nipples are round with equal in size.

Areola is same colour of complexion rounded.

Abdomen

Examination of abdomen include pigmentation if any, distension, respiratory movements, swelling, tenderness, visible peristalsis movement

Normally there is no pigmentation can be found on abdomen. Respiratory movements can be seen & some time normal patient may shows the visible peristalsis movement.

On auscultation –

One can hear bowel sound, peristalsis sound which are created by the presence of air and fluid in GI tract.

On palpation –

No mass, tenderness or lumps should be found in abdomen.  ( in appendicitis there is tenderness in right iliac fossa )

Swelling of liver also shows tenderness over right hypochondriac region

Swelling of spleen shows tenderness over left upper hypochondriac region.

Upper and Lower extremities

General observation and examination for movement, size, oedema, swelling, deformity. Always compare both legs and both hand together.

Normally they are equal in size. Equal in movement, no deformity, no swelling &  no oedema .

Generally in lower extremities see for varicosity of veins, it can felt by palpation

Palpation – this is for muscle tone, varicosity of veins , temperature (upper and lower both )

Skin

Observation and examination of skin includes any injuries, scars, wound, redness or irritation.

Also see for colour, patches, oedema, temperature and sensation. Normally skin colour is as per complexion and race . No oedema no patches normal temperature with normal sensation

 

About the author

Dr. Narendra

Narendra is a practicing doctor from India and has a passion for teaching. He loves to write and help others to understand the subject better with his influencing communication skill.

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