dando head-toe assessment
TRANSCRIPT
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Head: Shape and symmetry; condition of hair and scalp
Eyes:
Conjunctiva and sclera, pupils; reactivity to light and ability to follow your finger or a light
Ears: Hearing aids, pain? Speak in a whisper: can he hear you and comprehend? urn away to
make sure he isn!t reading your lips"
Nose: #rainage, congestion, difficulty breathing, sense of smell
Throat and Mouth: $ucous membranes, any lesions, teeth or dentures, odor, swallowing,
trachea, lymph nodes, tongue
%" &evel of Consciousness and 'rientation:
(s he awake and alert? (s he oriented to Person )knows his name*, Place )he can tell
you where he is* andTime )knows the day and date*" + fourth level of orientation
is Purpose )he knows why you are eamining him; or knows the function of something
such as your penlight or stethoscope*"
-" Skin:
+s you eamine all body systems you need to make note of the status of the (ntegumentary
System for any breaks in the skin, scars, lesions, wounds, redness, or irritat." horacicregion:
+ssess lung and cardiac sounds from the front and back" +ssess them for character and
/uality as well as for the presence or absence of appropriate sounds" 0alpate the chest
wall and breasts for any tenderness or lumps"
1" +bdomen:
&isten to bowel sounds throughout the - /uadrants" 0alpate for tenderness or lumps"
0alpate the bladder" +sk about intake and output of bowels and bladder" +sk about
appetite" +sses genitalia for tenderness, lumps or lesions"
2" 3tremities:
+ssess for temperature, capillary fill and 4'$" 0alpate for pulses" 5ote any edema,lesions, lumps or pain"
6" 7eneral 8uestions:
+sk the patient how he feels" Has anything changed recently? +ny pain, burning, S'9,
chest pains, change in bowel or bladder habitsfunction, change in sleep habits, cough,
discharge from any orifice, depression, sadness, or change in appetite? ion" +ssess theturgor, color, temperature and moisture of the skin"
Integument
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• Skin: The client’s skin is uniform in color, unblemished and
no presence of any foul odor. He has a good skin turgor and
skin’s temperature is within normal limit.
• Hair: The hair of the client is thick, silky hair is evenly
distributed and has a variable amount of body hair. There are
also no signs of infection and infestation observed.
• Nails: The client has a light brown nails and has the shape of
convex curve. It is smooth and is intact with the epidermis.
hen nails pressed between the !ngers "#lanch Test$, the
nails return to usual color in less than % seconds.
Head
• Head: The head of the client is rounded& normocephalic and
symmetrical.
• Skull: There are no nodules or masses and depressions
when palpated.
• Face: The face of the client appeared smooth and has
uniform consistency and with no presence of nodules or
masses.
'yes and (ision
• Eyebrows: Hair is evenly distributed. The client’s eyebrows
are symmetrically aligned and showed e)ual movement when
asked to raise and lower eyebrows.
• Eyelashes: 'yelashes appeared to be e)ually distributed
and curled slightly outward.
• Eyelids: There were no presence of discharges, no
discoloration and lids close symmetrically with involuntaryblinks approximately *+- times per minute.
• Eyes
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• The #ulbar con/unctiva appeared transparent with few
capillaries evident.
• The sclera appeared white.
• The palpebral con/unctiva appeared shiny, smooth and
pink.
• There is no edema or tearing of the lacrimal gland.
• 0ornea is transparent, smooth and shiny and the details
of the iris are visible. The client blinks when the cornea was
touched.
• The pupils of the eyes are black and e)ual in si1e. The
iris is 2at and round. 3'4456 "pupils e)ually round respond
to light accommodation$, illuminated and nonilluminated
pupils constricts. 3upils constrict when looking at near
ob/ect and dilate at far ob/ect. 3upils converge when ob/ect
is moved towards the nose.
• hen assessing the peripheral visual !eld, the client
can see ob/ects in the periphery when looking straight
ahead.
• hen testing for the 'xtraocular 7uscle, both eyes of
the client coordinately moved in unison with parallel
alignment.
• The client was able to read the newsprint held at a
distance of *% inches.
'ars and Hearing
• Ears: The 6uricles are symmetrical and has the same color
with his facial skin. The auricles are aligned with the outer
canthus of eye. hen palpating for the texture, the auricles
are mobile, !rm and not tender. The pinna recoils when folded.
8uring the assessment of atch tick test, the client was able
to hear ticking in both ears.
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9ose and inus
• Nose: The nose appeared symmetric, straight and uniform
in color. There was no presence of discharge or 2aring. henlightly palpated, there were no tenderness and lesions
• Mouth:
• The lips of the client are uniformly pink& moist,
symmetric and have a smooth texture. The client was able
to purse his lips when asked to whistle.
• Teeth and Gums: There are no discoloration of the
enamels, no retraction of gums, pinkish in color of gums
• The buccal mucosa of the client appeared as uniformly
pink& moist, soft, glistening and with elastic texture.
• The tongue of the client is centrally positioned. It is pink
in color, moist and slightly rough. There is a presence of
thin whitish coating.
• The smooth palates are light pink and smooth while the
hard palate has a more irregular texture.
• The uvula of the client is positioned in the midline of
the soft palate.
• Neck:
• The neck muscles are e)ual in si1e. The client showed
coordinated, smooth head movement with no discomfort.
• The lymph nodes of the client are not palpable.
• The trachea is placed in the midline of the neck.
• The thyroid gland is not visible on inspection and the
glands ascend during swallowing but are not visible.
Thorax, 5ungs, and 6bdomen
• Lungs / hest: The chest wall is intact with no tenderness
and masses. There’s a full and symmetric expansion and the
thumbs separate -; cm during deep inspiration when
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assessing for the respiratory excursion. The client manifested
)uiet, rhythmic and e
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6ssessment =indings
• kin hen skin is pinched it goes to
previous state immediately "-
seconds$.
ith fair complexion.
ith dry skin
• Hair 'venly distributed hair.
ith short, black and shiny hair.
ith presence of pediculosis
0apitis.
• 9ails mooth and has intact epidermis
ith short and clean !ngernails
and toenails.
0onvex and with good capillary
re!ll time of - seconds.
kull 4ounded, normocephalic and
symmetrical, smooth and has
uniform consistency.6bsence of
nodules or masses.
=ace ymmetrical facial movement,
palpebral !ssures e)ual in si1e,
symmetric nasolabial folds.
'yes and (ision
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6ssessment =indings
penlight which is held in an
obli)ue angle of the eye and
moving the light slowly across the
eye.
Has >brown? eyes.
• 0orneal sensitivity #links when the cornea is touched
through a cotton wisp from the
back of the client.
3upils #lack, e)ual in si1e with
consensual and direct reaction,
pupils e)ually rounded and
reactive to light and
accommodation, pupils constrict
when looking at near ob/ects,
dilates at far ob/ects, converge
when ob/ect is moved toward the
nose at four inches distance and
by using penlight.
(isual =ields hen looking straight ahead, the
client can see ob/ects at the
periphery which is done by having
the client sit directly facing the
nurse at a distance of -; feet.
The right eye is covered with a
card and asked to look directly at
the student nurse’s nose. Hold
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6ssessment =indings
penlight in the periphery and ask
the client when the moving ob/ect
is spotted.
(isual 6cuity 6ble to identify letter@read in the
newsprints at a distance of
fourteen inches.
3atient was able to read the
newsprint at a distance of A
inches.
'ar and Hearing
• 6uricles 0olor of the auricles is same as
facial skin, symmetrical, auricle is
aligned with the outer canthus of
the eye, mobile, !rm, nontender,
and pinna recoils after it is being
folded.
• 'xternal 'ar 0anal ithout impacted cerumen.
• Hearing 6cuity Test (oice sound audible.
• atch Tick Test6ble to hear ticking on right ear ata distance of one inch and was
able to hear the ticking on the left
ear at the same distance
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6ssessment =indings
9ose and sinuses
• 'xternal 9ose ymmetric and straight, no
2aring, uniform in color, air moves
freely as the clients breathes
through the nares.
• 9asal 0avity 7ucosa is pink, no lesions and
nasal septum intact and in middle
with no tenderness.
7outh and Bropharynx ymmetrical, pale lips, brown
gums and able to purse lips.
• Teeth ith dental caries and decayed
lower molars
• Tongue and 2oor of the
mouth
0entral position, pink but with
whitish coating which is normal,
with veins prominent in the 2oor
of the mouth.
• Tongue movement 7oves when asked to move
without diCculty and without
tenderness upon palpation.
Dvula 3ositioned midline of soft palate.
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6ssessment =indings
Eag 4e2ex 3resent which is elicited through
the use of a tongue depressor.
9eck 3ositioned at the midline without
tenderness and 2exes easily. 9o
masses palpated.
Head movement 0oordinated, smooth movement
with no discomfort, head laterally
2exes, head laterally rotates and
hyperextends.
7uscle strength ith e)ual strength
5ymph 9odes 9onpalpable, non tender
• Thyroid Eland 9ot visible on inspection, glands
ascend but not visible in female
during swallowing and visible in
males.
Thorax and lungs
3osterior thorax 0hest symmetrical
• pinal alignment pine vertically aligned, spinal
column is straight, left and right
shoulders and hips are at the
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6ssessment =indings
same height.
#reath ounds ith normal breath sounds
without dyspnea.
• 6nterior Thorax Fuiet, rhythmic and e
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6ssessment =indings
resistance.
#ones and oints 9o deformities or swelling, /oints
move smoothly.
7ental tatus
5anguage 0an express oneself by speech or
sign.
Brientation Briented to a person, place, date
or time.
6ttention span 6ble to concentrate as evidence
by answering the )uestions
appropriately.
5evel of 0onsciousness 6 total of *+ points indicative of
complete orientation andalertness.
7otor =unction
Eross 7otor and #alance
• alking gait Has upright posture and steady
gait with opposing arm swing
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6ssessment =indings
unaided and maintaining balance.
tanding on one foot with eyes
closed
7aintained stance for at least !ve
"+$ seconds.
Heel toe walking 7aintains a heel toe walking
along a straight line
Toe or heel walking 6ble to walk several steps in
toes@heels.
=ine motor test for Dpper
'xtremities
=inger to nose test 4epeatedly and rhythmically
touches the nose.
6lternating supination and
pronation of hands on knees
0an alternately supinate and
pronate hands at rapid pace.
=inger to nose and to the nurse’s
!nger
3erform with coordinating and
rapidity.
=ingers to !ngers 3erform with accuracy and
rapidity.
=ingers to thumb 4apidly touches each !nger to
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6ssessment =indings
thumb with each hand.
=ine motor test for the 5ower
'xtremities
3ain sensation 6ble to discriminate between
sharp and dull sensation when
touched with needle and cotton.
kull, calp Hair
• Bbserve the si1e, shape and contour of the skull.
• Bbserve scalp in several areas by separating the hair at
various locations& in)uire about any in/uries. 9ote presence of
lice, nits, dandru< or lesions.
• 3alpate the head by running the pads of the !ngers over the
entire surface of skull& in)uire about tenderness upon doing so.
"wear gloves if necessary$
• Bbserve and feel the hair condition.
Normal Findings:
kull
• Eenerally round, with prominences in the frontal and
occipital area. "9ormocephalic$.
• 9o tenderness noted upon palpation.
calp
• 5ighter in color than the complexion.
• 0an be moist or oily.
• 9o scars noted.
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• The normal response in blinking.
2. Motor function
• 6sk the client to chew or clench the /aw.
• The client should be able to clench or chew with strength
and force.
09 (II "=acial$
1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).
• 3lace a sweet, sour, salty, or bitter substance near the tip of
the tongue.
• 9ormally, the client can identify the taste.
2. Motor function
• 6sk the client to smile, frown, raise eye brow, close eye lids,
whistle, or pu< the cheeks.
Normal Findings
• hape maybe oval or rounded.
• =ace is symmetrical.
• 9o involuntary muscle movements.
• 0an move facial muscles at will.
• Intact cranial nerve ( and (II.
'yebrows, 'yes and 'yelashes
• 6ll three structures are assessed using the modality of
inspection.
Normal fndings
'yebrows
• ymmetrical and in line with each other.
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• 7aybe black, brown or blond depending on race.
• 'venly distributed.
evere exopthalmos
'yes
• 'venly placed and inline with each other.
• 9one protruding.
• ')ual palpebral !ssure.
'yelashes
• 0olor dependent on race.
• 'venly distributed.
• Turned outward.
'yelids and 5acrimal 6pparatus
• Inspect the eyelids for position and symmetry.
• 3alpate the eyelids for the lacrimal glands.
• To examine the lacrimal gland, the examiner, lightly
slide the pad of the index !nger against the client’s upper
orbital rim.
• In)uire for any pain or tenderness.
• 3alpate for the nasolacrimal duct to check for obstruction.
• To assess the nasolacrimal duct, the examiner presses
with the index !nger against the client’s lower inner orbital
rim, at the lacrimal sac,N$T !G!%NST THE N$SE&
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• In the presence of blockage, this will cause
regurgitation of 2uid in the puncta
Normal Findings
'yelids
• Dpper eyelids cover the small portion of the iris, cornea, and
sclera when eyes are open.
• 9o 3TBI noted. "8rooping of upper eyelids$.
•
7eets completely when eyes are closed.• ymmetrical.
5acrimal 6pparatus
• 5acrimal gland is normally non palpable.
• 9o tenderness on palpation.
• 9o regurgitation from the nasolacrimal duct.
0on/unctivae
• The bulbar and palpebral con/unctivae are examined by
separating the eyelids widely and having the client look up,
down and to each side. hen separating the lids, the
examiner should exert 9B 34'D4' against the eyeball&
rather, the examiner should hold the lids against the ridges of
the bony orbit surrounding the eye.
In examining the pape!ra con"unctiva# everting the upper eyei$ in necessary
an$ is $one as foo%&
*. 6sk the client to look down but keep his eyes slightly open.
This relaxes the levator muscles, whereas closing the eyes
contracts the orbicularis muscle, preventing lid eversion.
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-. Eently grasp the upper eyelashes and pull gently downward.
8o not pull the lashes outward or upward& this, too, causes
muscles contraction.
;. 3lace a cotton tip application about I can above the lid
margin and push gently downward with the applicator while
still holding the lashes. This everts the lid.
%. Hold the lashes of the everted lid against the upper ridge of
the bony orbit, /ust beneath the eyebrow, never pushing
against the eyebrow.
+. 'xamine the lid for swelling, infection, and presence of
foreign ob/ects.
J. To return the lid to its normal position, move the lid slightly
forward and ask the client to look up and to blink. The lid
returns easily to its normal position.
Normal Findings
• #oth con/unctiva are pinkish or red in color.
• ith presence of many minutes capillaries.
• 7oist
• 9o ulcers
• 9o foreign ob/ects
clerae
• The sclerae is easily inspected during the assessment of the
con/unctivae.
Normal Findings
• clerae is white in color "anicteric sclera$
• 9o yellowish discoloration "icteric sclera$.
• ome capillaries maybe visible.
• ome people may have pigmented positions.
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0ornea
• The cornea is best inspected by directing penlight obli)uely
from several positions.
Normal fndings
• There should be no irregularities on the surface.
• 5ooks smooth.
• The cornea is clear or transparent. The features of the iris
should be fully visible through the cornea.• There is a positive corneal re2ex.
6nterior 0hamber and Iris
• The anterior chamber and the iris are easily inspected in
con/unction with the cornea. The techni)ue of obli)ue
illumination is also useful in assessing the anterior chamber.
Normal Findings
• The anterior chamber is transparent.
• 9o noted any visible materials.
• 0olor of the iris depends on the person’s race "black, blue,
brown or green$.
• =rom the side view, the iris should appear 2at and should not
be bulging forward. There should be 9B crescent shadow
casted on the other side when illuminated from one side.
3upils
• 'xamination of the pupils involves several inspections,
including assessment of the si1e, shape reaction to light is
directed is observed for direct response of constriction.
imultaneously, the other eye is observed for consensual
response of constriction.
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• The test for papillary accommodation is the examination for
the change in papillary si1e as it is switched from a distant to a
near ob/ect.
• 6sk the client to stare at the ob/ects across room.
• Then ask the client to !x his ga1e on the examiner’s index
!ngers, which is placed + K + inches from the client’s nose.
• (isuali1ation of distant ob/ects normally causes papillary
dilation and visuali1ation of nearer ob/ects causes papillary
constriction and convergence of the eye.
Normal Findings
• 3upillary si1e ranges from ; K L mm, and are e)ual in si1e.
• ')ually round.
• 0onstrict briskly@sluggishly when light is directed to the eye,
both directly and consensual.
• 3upils dilate when looking at distant ob/ects, and constrict
when looking at nearer ob/ects.
• If all of which are met, we document the !ndings using the
notation 3'4456, pupils e)ually round, reactive to light, and
accommodate
6 nellen chart
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0ranial 9erve II "optic nerve$
• The optic nerve is assessed by testing for visual acuity and
peripheral vision.• (isual acuity is tested using a snellen chart, for those who
are illiterate and unfamiliar with the western alphabet, the
illiterate ' chart, in which the letter ' faces in di
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movement about *- inches from their eyes, or if they can
perceive the light of the penlight directed to their yes.
3eripheral vision or visual !elds
• The assessment of visual acuity is indicative of the
functioning of the macular area, the area of central vision.
However, it does not test the sensitivity of the other areas of
the retina which perceive the more peripheral stimuli. The
(isual !eld confrontation test, provide a rather gross
measurement of peripheral vision.
• The performance of this test assumes that the examiner has
normal visual !elds, since that client’s visual !elds are to be
compared with the examiners.
Foo% the steps on con$ucting the test&
• The examiner and the client sit or stand opposite each other,
with the eyes at the same, hori1ontal level with the distance of
*.+ K - feet apart.
• The client covers the eye with opa)ue card, and the
examiner covers the eye that is opposite to the client covered
eye.
• Instruct the client to stare directly at the examiner’s eye,
while the examiner stares at the client’s open eye. 9either
looks out at the ob/ect approaching from the periphery.
• The examiner hold an ob/ect such as pencil or penlight, in his
hand and gradually moves it in from the periphery of both
directions hori1ontally and from above and below.
• 9ormally the client should see the same time the examiners
sees it. The normal visual !eld is *A degrees.
'rania erve III# I * I (+cuomotor# Trochear# ,!$ucens)
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• 6ll the ; 0ranial nerves are tested at the same time by
assessing the 'xtra Bcular 7ovement "'B7$ or the six cardinal
position of ga1e.
Follow the given steps:
• tand directly in front of the client and hold a !nger or a
penlight about * ft from the client’s eyes.
• Instruct the client to follow the direction the ob/ect hold by
the examiner by eye movements only& that is with out moving
the neck.
• The nurse moves the ob/ect in a clockwise direction
hexagonally.
• Instruct the client to !x his ga1e momentarily on the
extreme position in each of the six cardinal ga1es.
• The examiner should watch for any /erky movements of the
eye "nystagmus$.
• 9ormally the client can hold the position and there should be
no nystagmus.
'ars
• Inspect the auricles of the ears for parallelism, si1e position,
appearance and skin color.
• 3alpate the auricles and the mastoid process for !rmness of
the cartilage of the auricles, tenderness when manipulating
the auricles and the mastoid process.
• Inspect the auditory meatus or the ear canal for color,
presence of cerumen, discharges, and foreign bodies.
• =or adult pull the pinna upward and backward to straiten the
canal.
• =or children pull the pinna downward and backward to
straiten the canal
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• 3erform otoscopic examination of the tympanic membrane,
noting the color and landmarks.
Normal Findings
• The ear lobes are bean shaped, parallel, and symmetrical.
• The upper connection of the ear lobe is parallel with the
outer canthus of the eye.
• kin is same in color as in the complexion.
• 9o lesions noted on inspection.
• The auricles are has a !rm cartilage on palpation.
• The pinna recoils when folded.
• There is no pain or tenderness on the palpation of the
auricles and mastoid process.
• The ear canal has normally some cerumen of inspection.
• 9o discharges or lesions noted at the ear canal.
• Bn otoscopic examination the tympanic membrane appears
2at, translucent and pearly gray in color.
9ose and 3aranasal inuses
• The external portion of the nose is inspected for the
following:
• 3lacement and symmetry.
• 3atency of nares "done by occluding nosetril one at a
time, and noting for diCculty in breathing$
• =laring of alae nasi
• 8ischarge
• The external nares are palpated for:
• 8isplacement of bone and cartilage.
• =or tenderness and masses
• The internal nares are inspected by hyper extending the
neck of the client, the ulnar aspect of the examiners hard
over the fore head of the client, and using the thumb to
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push the tip of the nose upward while shining a light into
the nares.
• Inspect for the following:
• 3osition of the septum.
• 0heck septum for perforation. "0an also be checked by
directing the lighted penlight on the side of the nose,
illumination at the other side suggests perforation$.
• The nasal mucosa "turbinates$ for swelling, exudates
and change in color.
3aranasal inuses
• 'xamination of the paranasal sinuses is indirectly.
Information about their condition is gained by inspection and
palpation of the overlying tissues. Bnly frontal and maxillary
sinuses are accessible for examination.
• #y palpating both cheeks simultaneously, one can determine
tenderness of the maxillary sinusitis, and pressing the thumb
/ust below the eyebrows, we can determine tenderness of the
frontal sinuses.
Normal Findings
• 9ose in the midline
• 9o 8ischarges.
• 9o 2aring alae nasi.
• #oth nares are patent.
• 9o bone and cartilage deviation noted on palpation.
• 9o tenderness noted on palpation.
• 9asal septum in the mid line and not perforated.
• The nasal mucosa is pinkish to red in color. "Increased
redness turbinates are typical of allergy$.
• 9o tenderness noted on palpation of the paranasal sinuses.
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0ranial 9erve I "Blfactory 9erve$
• To test the ade)uacy of function of the olfactory nerve:
•
The client is asked to close his eyes and occlude.• The examiner places aromatic and easily distinguish
nose. "'.g. alcohol, vinegar, co
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-apate$ for&
• Texture
Normal Findings:
• 3inkish with white taste buds on the surface.
• 9o lesions noted.
• 9o varicosities on ventral surface.
• =renulum is thin attaches to the posterior *@; of the ventral
aspect of the tongue.
• Eag re2ex is present.
• 6ble to move the tongue freely and with strength.
• urface of the tongue is rough.
Dvula
Inspecte$ for&
• 3osition
• 0olor
• 0ranial 9erve M "(agus nerve$ K Tested by asking the client
to say N6hO note that the uvula will move upward and forward.
Normal Findings:
• 3ositioned in the mid line.
• 3inkish to red in color.
• 9o swelling or lesion noted.
• 7oves upward and backwards when asked to say NahO
Tonsils
Inspecte$ for&
• In2ammation
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• i1e
• 6 Erading system used to describe the si1e of the tonsils can
be used.
• Erade * K Tonsils behind the pillar.
• Erade - K #etween pillar and uvula.
• Erade ; K Touching the uvula
• Erade % K In the midline.
9eck
• The neck is inspected for position symmetry and obvious
lumps visibility of the thyroid gland and ugular (enous
8istension
• 0heck the 4ange of 7ovement of the neck.
Normal Findings:
• The neck is straight.
• 9o visible mass or lumps.
• ymmetrical
• 9o /ugular venous distension "suggestive of cardiac
congestion$.
• The neck is palpated /ust above the suprasternal note using
the thumb and the index !nger.
Normal Findings:
• The trachea is palpable.
• It is positioned in the line and straight.
• 5ymph nodes are palpated using palmar tips of the !ngers
via systemic circular movements. 8escribe lymph nodes in
terms of si1e, regularity, consistency, tenderness and !xation
to surrounding tissues.
Normal Findings:
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• 7ay not be palpable. 7aybe normally palpable in thin
clients.
• 9on tender if palpable.
• =irm with smooth rounded surface.
• lightly movable.
• 6bout less than * cm in si1e.
• The thyroid is initially observed by standing in front of the
client and asking the client to swallow. 3alpation of the thyroid
can be done either by posterior or anterior approach.
Posterior Approach:
*. 5et the client sit on a chair while the examiner stands behind
him.
-. In examining the isthmus of the thyroid, locate the cricoid
cartilage and directly below that is the isthmus.
;. 6sk the client to swallow while feeling for any enlargement
of the thyroid isthmus.
%. To facilitate examination of each lobe, the client is asked to
turn his head slightly toward the side to be examined to
displace the sternocleidomastoid, while the other hand of the
examiner pushes the thyroid cartilage towards the side of the
thyroid lobe to be examined.
+. 6sk the patient to swallow as the procedure is being done.
J. The examiner may also palate for thyroid enlargement by
placing the thumb deep to and behind the sternocleidomastoid
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muscle, while the index and middle !ngers are placed deep to
and in front of the muscle.
L. Then the procedure is repeated on the other side.
Anterior approach:
*. The examiner stands in front of the client and with the
palmar surface of the middle and index !ngers palpates below
the cricoid cartilage.
-. 6sk the client to swallow while palpation is being done.
;. In palpating the lobes of the thyroid, similar procedure is
done as in posterior approach. The client is asked to turn his
head slightly to one side and then the other of the lobe to be
examined.
%. 6gain the examiner displaces the thyroid cartilage towards
the side of the lobe to be examined.
+. 6gain, the examiner palpates the area and hooks thumb and
!ngers around the sternocleidomastoid muscle.
Normal Findings:
• 9ormally the thyroid is non palpable.
• Isthmus maybe visible in a thin neck.
• 9o nodules are palpable.
• 6uscultation of the Thyroid is necessary when there is
thyroid enlargement. The examiner may hear bruits, as a
result of increased and turbulence in blood 2ow in an enlarged
thyroid.
Thorax "0ardiovascular ystem$
Inspection of the Heart
• The chest wall and epigastrum is inspected while the client is
in supine position. Bbserve for pulsation and heaves or lifts
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Normal Findings:
• 3ulsation of the apical impulse maybe visible. "this can give
us some indication of the cardiac si1e$.
• There should be no lift or heaves.
3alpation of the Heart
• The entire precordium is palpated methodically using the
palms and the !ngers, beginning at the apex, moving to the
left sternal border, and then to the base of the heart.
Normal Findings:
• 9o, palpable pulsation over the aortic, pulmonic, and mitral
valves.
• 6pical pulsation can be felt on palpation.
•
There should be no noted abnormal heaves, and thrills feltover the apex.
3ercussion of the Heart
• The techni)ue of percussion is of limited value in cardiac
assessment. It can be used to determine borders of cardiac
dullness.
6uscultation of the Heart
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• 6natomic areas for auscultation of the heart:
• 6ortic valve K 4ight -nd I0 sternal border.
• 3ulmonic (alve K 5eft -nd I0 sternal border.
• Tricuspid (alve K K 5eft +th I0 sternal border.
• 7itral (alve K 5eft +th I0 midclavicular line
Positioning the client for auscultation:
*. If the heart sounds are faint or undetectable, try listening to
them with the patient seated and learning forward, or lying on
his left side, which brings the heart closer to the surface of the
chest.
-. Having the client seated and learning forward s best suited
for hearing highpitched sounds related to semilunar valves
problem.
;. The left lateral recumbent position is best suited lowpitched
sounds, such as mitral valve problems and extra heart sounds.
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Auscultating the heart:
*. 6uscultate the heart in all anatomic areas aortic, pulmonic,
tricuspid and mitral
-. 5isten for the * and - sounds "* closure of 6( valves& -
closure of semilunar valve$. * sound is best heard over the
mitral valve& - is best heard over the aortric valve.
;. 5isten for abnormal heart sounds e.g. ;, %, and 7urmurs.
%. 0ount heart rate at the apical pulse for one full minute.
6uscultation of Heart ounds
Normal Findings:
• * - can be heard at all anatomic site.
• 9o abnormal heart sounds is heard "e.g. 7urmurs, ; %$.
• 0ardiac rate ranges from J K * bpm.
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#reast
Inspection of the #reast
• There are % ma/or sitting position of the client used for
clinical breast examination. 'very client should be examined in
each position.• The client is seated with her arms on her side.
• The client is seated with her arms abducted over the
head.
• The client is seated and is pushing her hands into her
hips, simultaneously eliciting contraction of the pectoral
muscles.• The client is seated and is learning over while the
examiner assists in supporting and balancing her.
• hile the client is performing these maneuvers, the breasts
are carefully observed for symmetry, bulging, retraction, and
!xation.
• 6n abnormality may not be apparent in the breasts at rest a
mass may cause the breasts, through invasion of the
suspensory ligaments, to !x, preventing them from upward
movement in position - and %.
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• 3osition ; speci!cally assists in eliciting dimpling if a mass
has in!ltrated and shortened suspensory ligaments.
Normal Findings:
• The overlying the breast should be even.
• 7ay or may not be completely symmetrical at rest.
• The areola is rounded or oval, with same color, "0olor va,ies
form light pink to dark brown depending on race$.
• 9ipples are rounded, everted, same si1e and e)ual in color.
• 9o Norange peelO skin is noted which is present in edema.
• The veins maybe visible but not engorge and prominent.
• 9o obvious mass noted.
• 9ot !xated and moves bilaterally when hands are abducted
over the head, or is learning forward.
• 9o retractions or dimpling.
3alpation of the #reast
• 3alpate the breast along imaginary concentric circles,
following a clockwise rotary motion, from the periphery to the
center going to the nipples. #e sure that the breast is
ade)uately surveyed. #reast examination is best done * week
post menses.
• 'ach areolar areas are carefully palpated to determine the
presence of underlying masses.
• 'ach nipple is gently compressed to assess for the presence
of masses or discharge.
Normal Findings:
• 9o lumps or masses are palpable.
• 9o tenderness upon palpation.
• 9o discharges from the nipples.
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• 9BT': The male breasts are observed by adapting the
techni)ues used for female clients. However, the various
sitting position used for woman is unnecessary.
6bdomen• In abdominal assessment, be sure that the client has
emptied the bladder for comfort. 3lace the client in a supine
position with the knees slightly 2exed to relax abdominal
muscles.
Inspection of the abdomen
• Inspect for skin integrity "3igmentation, lesions, striae, scars,
veins, and umbilicus$.
• 0ontour "2at, rounded, scapold$
• 8istension
• 4espiratory movement.
• (isible peristalsis.
• 3ulsations
Normal Findings:
• kin color is uniform, no lesions.
• ome clients may have striae or scar.
• 9o venous engorgement.
• 0ontour may be 2at, rounded or scapoid
• Thin clients may have visible peristalsis.
• 6ortic pulsation maybe visible on thin clients.
6uscultation of the 6bdomen
•
This method precedes percussion because bowel motility,and thus bowel sounds, may be increased by palpation or
percussion.
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• The stethoscope and the hands should be warmed& if they
are cold, they may initiate contraction of the abdominal
muscles.
• 5ight pressure on the stethoscope is suCcient to detect
bowel sounds and bruits. Intestinal sounds are relatively high
pitched, the bell may be used in exploring arterial murmurs
and venous hum.
3eristaltic sounds
• These sounds are produced by the movements of air and
2uids through the gastrointestinal tract. 3eristalsis can provide
diagnostic clues relevant to the motility of bowel.
• 5istening to the bowel sounds "borborygmi$ can be
facilitated by following these steps:
• 8ivide the abdomen in four )uadrants.
• 5isten over all auscultation sites, starting at the right
lower )uadrants, following the cross pattern of the
imaginary lines in creating the abdominal )uadrants. This
direction ensures that we follow the direction of bowel
movement.
• 3eristaltic sounds are )uite irregular. Thus it is
recommended that the examiner listen for at least +
minutes, especially at the periumbilical area, before
concluding that no bowel sounds are present.
• The normal bowel sounds are highpitched, gurgling
noises that occur approximately every + K *+ seconds. It is
suggested that the number of bowel sound may be as low
as ; to as high as - per minute, or roughly, one bowel
sound for each breath sound.
• ome factors that a
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• tate of digestion.
• 3athologic conditions of the bowel "in2ammation,
Eangrene, paralytic ileus, peritonitis$.
• #owel surgery
• 0onstipation or 8iarrhea.
• 'lectrolyte imbalances.
• #owel obstruction.
3ercussion of the abdomen
• 6bdominal percussion is aimed at detecting 2uid in the
peritoneum "ascites$, gaseous distension, and masses, and in
assessing solid structures within the abdomen.
• The direction of abdominal percussion follows the
auscultation site at each abdominal guardant.
• The entire abdomen should be percussed lightly or a general
picture of the areas of tympany and dullness.
• Tympany will predominate because of the presence of gas in
the small and large bowel. olid masses will percuss as dull,
such as liver in the 4DF, spleen at the Jth or Pth rib /ust
posterior to or at the mid axillary line on the left side.
• 3ercussion in the abdomen can also be used in assessing the
liver span and si1e of the spleen.
3ercussion of the liver
• The palms of the left hand are placed over the region of liver
dullness.
• The area is strucked lightly with a !sted right hand.
•
9ormally tenderness should not be elicited by this method.• Tenderness elicited by this method is usually a result of
hepatitis or cholecystitis.
4enal 3ercussion
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• 0an be done by either indirect or direct method.
• 3ercussion is done over the costovertebral /unction.
• Tenderness elicited by such method suggests renal
in2ammation.
3alpation of the 6bdomen
Light palpation
• It is a gentle exploration performed while the client is in
supine position. ith the examiner’s hands parallel to the2oor.
• The !ngers depress the abdominal wall, at each )uadrant, by
approximately * cm without digging, but gently palpating with
slow circular motion.
• This method is used for eliciting slight tenderness, large
masses, and muscles, and muscle guarding.• Tensing of abdominal musculature may occur because of:
• The examiner’s hands are too cold or are pressed to
vigorously or deep into the abdomen.
• The client is ticklish or guards involuntarily.
• 3resence of sub/acent pathologic condition.
Normal Findings:
• 9o tenderness noted.
• ith smooth and consistent tension.
• 9o muscles guarding.
Deep Palpation
• It is the indentation of the abdomen performed by pressing
the distal half of the palmar surfaces of the !ngers into the
abdominal wall.
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• The abdominal wall may slide back and forth while the
!ngers move back and forth over the organ being examined.
• 8eeper structures, like the liver, and retro peritoneal organs,
like the kidneys, or masses may be felt with this method.
• In the absence of disease, pressure produced by deep
palpation may produce tenderness over the cecum, the
sigmoid colon, and the aorta.
5iver palpation
• There are two types of bi manual palpation recommended for
palpation of the liver. The !rst one is the superimposition of
the right hand over the left hand.
• 6sk the patient to take ; normal breaths.
• Then ask the client to breath deeply and hold. This
would push the liver down to facilitate palpation.
• 3ress hand deeply over the 4DF
• The second methods:
• The examiner’s left hand is placed beneath the client at
the level of the right **th and *-th ribs.
• 3lace the examiner’s right hands parallel to the costal
margin or the 4DF.
• 6n upward pressure is placed beneath the client to
push the liver towards the examining right hand, while the
right hand is pressing into the abdominal wall.
• 6sk the client to breath deeply.
• 6s the client inspires, the liver maybe felt to slip
beneath the examining !ngers.
Normal Findings:
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• The liver usually can not be palpated in a normal adult.
However, in extremely thin but otherwise well individuals, it
may be felt the coastal margins.
• hen the normal liver margin is palpated, it must be
smooth, regular in contour, !rm and nontender.
'xtremities
Inspection
• Bbserve for si1e, contour, bilateral symmetry, and
involuntary movement.
• 5ook for gross deformities, edema, presence of trauma such
as ecchymosis or other discoloration.
• 6lways compare both extremities.
3alpation
• =eel for evenness of temperature. 9ormally it should be even
for all the extremities.
• Tonicity of muscle. "0an be measured by asking client to
s)uee1e examiner’s !ngers and noting for e)uality of
contraction$.
• 3erform range of motion.
•
Test for muscle strength. "performed against gravity andagainst resistance$
• Table showing the 5ovett scale for grading for muscle
strength and functional level
=unctional level 5ovett
cale
Erad
e
3ercentage of
normal
9o evidence of contractility Qero "Q$
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'vidence of slight contractility Trace
"T$
* *
0omplete 4B7 without gravity 3oor "3$ - -+
0omplete 4B7 with gravity =air "=$ ; +
0omplete range of motion against
gravity with some resistance
Eood
"E$
% L+
0omplete range of motion against
gravity with full resistance
9ormal
"9$
+ *
Normal Findings
• #oth extremities are e)ual in si1e.
• Have the same contour with prominences of /oints.
• 9o involuntary movements.
• 9o edema
• 0olor is even.
• Temperature is warm and even.
• Has e)ual contraction and even.
• 0an perform complete range of motion.
• 9o crepitus must be noted on /oints.