head to toe assessment (body parts)
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Body PartsAssessment of Body Parts
Head & NeckHeadInspection:For size, shape & symmetry
Palpation:For contour, masses, depressions.
HairInspection:For color, evenness of growth overthe scalp, presence of parasites,amount of body hair.
Palpation:Thickness or thinness texture and
oiliness.
ScalpInspection:For Color, oiliness, presence ofscars, lice and dandruff.
Palpation:For lesions or masses tenderness.
ForeheadInspection:For symmetry, skin appearance,presence of rushes, scars orpimples.
Normal Findings
The head should be round(normocephalic) and symmetrical.
The normal skull is smooth, andwithout masses or depressions,non tender.
Can be black, brown or burgundydepending on the race, evenlydistributed covers the whole scalp(no evidences of Alopecia), noparasites, and the amount isvariable.
Maybe thick or thin, coarse or
smooth neither brittle nor dry.
Lighter in color than thecomplexion, can be moist or oily,no scars noted, free from lice, nitsand dandruff.
NO lesions should be noted,
neither tenderness nor masses.
Symmetrical, light to dark brown,no rushes, scars and pimples.
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Palpation:For masses, lumps and tenderness
FaceInspection:
For shape and symmetry,presence of scars, pimples or acne
Palpation:For any swelling, masses, lumps,and the four sinuses (sphenoidal
sinuses, frontal sinuses, ethmoidsinuses and maxillary sinuses).
EyesInspection:For symmetry.
EyebrowsInspection:
For hair distribution and alignmentand skin quality and movement,presence of pimples, dandruff andcolor of the hair.
Palpation:For the presence of lumps, painand nodules.
Eyelashes
Inspection:For evenness of distribution anddirection of curl and color
ScleraInspection:For color, moisture, texture andthe presence of lesions.
Non-tender, no lumps andabsence of masses.
The shape of the face can be oval,round, or slightly square, the faceis symmetrical, absence of scars,pimples or acne. There should beno edema, disproportionatestructures, or involuntarymovements.
No lumps and swelling of the face,absence of masses and there is no
pain felt during palpation of face
Symmetrical or evenly placed andinline with each other. Nonprotruding and equal palpebralfissure.
Hair evenly distributed; skinintact. Eyebrows symmetricallyaligned; equal movement,absence of pimples and dandruff,maybe black brown or blonddepending on race.
No lumps, no nodules and no painfelt during palpation
Equally distributed; curled sightlyoutward and black in color.
The sclera appears white,
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Conjunctivae
Inspection:For lesions, swelling, color andmoisture.
Palpation:Presence of pain
CorneaInspection:For clarity, texture and moisture
IrisInspection:For appearance, coloration andshape.
PupilInspection:
For color size, shape and equalityof the pupils
Muscle functionCorneal Light Reflex or theHirschberg Test(Observe the location of reflectedlight on the cornea)
Cover TestThis test detects small degrees ofdeviated alignment byinterrupting the fusion reflex thatnormally keeps two eyes parallel.(Observe the cover eye formovement)
although blacks occasionally havea gray-blue or muddy color tosclera. It should be moist andwithout lesions
Both conjunctivae are shiny,smooth, and pink or red, absenceof swelling, no lesions and itshould be moist.
There should be no pain feltduring palpation.
The corneal surface should bemoist, shiny and transparent, withno discharges and cloudiness.
The iris is normally appears flat,with a regular shape and evencoloration.
Black in color; appears round,regular, smooth border and ofequal size in both eyes, normally3-7 mm in diameter.
The reflected light (light reflexes)should be seen symmetrically in
the centers of the cornea.
If the eyes are in alignment, therewill be no movement of the eithereye.
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Diagnostic Position testLeading the eye through the sixcardinal positions of gaze will elicitany muscle weakness during
movement. (Observe forconvergence of gaze).
Muscle balanceTest for pupilary lightreflex(Cardinal Fields of Gaze)
Test for Accommodation
Visual AcuitySnellen eye ChartThe Snellen eye chart is the mostcommonly used and accuratemeasure of visual acuity.
Peripheral Vision
A normal response is paralleltracking of the object with botheyes. Both eyes should move
smoothly and symmetrically ineach of the six fields gaze andconvergence on the held object asit moves toward the nose.
Normally you will see:-Constriction of the same-sidedpupil (a direct light reflex).-Simultaneously (a consensuallight reflex).
A normal response includes:-Papillary constriction.-Convergence of the axes of theeye.Record the normal response to allthese maneuver as:P - PupilsE - Equal
R - RoundR - React toL - Light andA - Accommodation
Normal Visual is 20/20The Top number (numerator)indicates the distance the person
is standing from the chart, whilethe denominator gives thedistance at which a normal eyecould have read that particularline. Thus 20/20 means you canread that 20 ft. with the normaleye could have read at 20 ft.
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Test Visual FieldsConfrontation Test
NoseExternal Inspection:Inspect the nose nothing anybleeding, inflammation, or lesions,masses, swelling, and symmetry,discharges and color, sense ofsmell.
External Palpation:For tenderness and presence ofpain.
Internal Inspection:Inspect for nasal septum fordeviation, perforation, lesions andbleeding.
Frontal SinusesInspection:For any swelling around the eyes
Palpation:Presence of pain and tenderness
Percussion:
Note any sound
Maxillary SinusesInspection:For any swelling around the eyesPalpation:Presence of pain and tenderness
The patient is able to see thestimulus at about 90 degreestemporally, 60 degrees nasally, 50degrees superiorly, and 70degrees inferiorly.
The shape of the external nosecan vary greatly among individual.Normally, it is locatedsymmetrically on the midline ofthe face that is without swelling,bleeding, lesions, or masses. Nodischarge or flaring and uniform
color, there is a sense of smell.
Non-tender; absence of pain
The nasal mucosa should be pinkor dull red without swelling. Theseptum is at the midline andwithout perforation, lesions or
bleeding, the small amount ofwatery discharge is normal.
There is no evidence of swellingaround the eyes.
The patient should not feel painduring palpation and notenderness felt.
The sound should be flat or dull.
There is no evidence of swellingaround the nose and eyes.The patient should not feel anypain and tenderness during
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Percussion:Note any sound
Transillumination of thesinusesYou may use this technique in thefrontal and maxillary sinuses whenyou suspect sinus inflammation,although it is of limited usefulness.
MouthLipsInspection:For color, texture, cracking,
symmetry, lesions and hydration
Palpation:For any presence of pain, lumpsand tenderness.
GumsInspection:For color, texture, swelling,bleeding, retraction form the teeth
Palpation:For the presence of pain,tenderness and lumps.
TeethInspection:For discoloration, numbers of
tooth and texture.
TongueInspection:For color, texture, surface
palpation.
The sound should be flat or dull.
The glow on each side is equal,indication air-filled frontal andmaxillary sinuses.
The lips should be pink, soft moist,
smooth texture with no evidenceof lesions or inflammation. Notcrack and symmetrical.
There is no presence of lumps andpain. It is tender.
The gums should be pink, moist,firm texture, no retraction, no
swelling or bleeding. The gummargins at the teeth are tight andwell-defined.
There should be no pain feltduring palpation, no lumps andnon-tender.
The adult normally has 32 teeth,which should be white, straight
and smooth edges in properalignment or evenly placed, cleanand free of debris or decay.
The tongue is in the midline of themouth, the dorsal surface shouldbe pink, moist, rough and without
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characteristics, symmetry,presence of lesions, and sense oftaste.
Palpation:For any nodules, lumps andpresence of pain
FrenulumInspection:For the color, texture.
Sublingual AreaInspection:For color, moisture and presenceof lesion.
Hard palateInspection:For color, shape, texture,presence of lesions andmalformation.
Soft PalateInspection:For color, shape, texture,presence of lesions, malformation
UvulaInspection:For position, mobility and color.
TonsilsInspection:For color, shape, size and
lesions. The tongue is symmetricaland moves freely. The strength ofthe tongue is symmetrical andstrong.The ventral surface of the tongue
ahs prominent blood vessels andshould be moist without lesions,looks smooth and glistening.There is a sense of taste.
There should be no presence ofnodules, lumps and pain.
It should be attached to the
tongue, pinkish in color and moist.
It should be pink in color, moistand no presence of lesions.
The hard palate is concave andlighter in pink in color, it has manyridges and it is moist, without any
lesion or malformation.
The soft palate is also concaveand light pink in color, it is smoothand no lesions or malformationsnoted.
It normally looks like a fleshpendant hanging in the midline of
soft palate. Tonsils are presentand pink in color.
It is pink in color and smooth. Ovalin shape. No discharge. Of normalsize or not visible, no
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discharge.
Palpation:Presence of pain
EarsExternal earInspection:For position, color, size, shape,any deformities, inflammation, orlesions
Palpation:Presence of pain, tenderness, andlumps.
Auditory AcuityVoice-Whisper test
Tuning fork test
Webers Test
Rinnes Test
inflammation, and not swollen.
There should be no pain feltduring palpation.
The ear matches the flesh color ofthe rest of the patients skin andshould be positioned centrally andin proportion to the head. The topof the ear should cross animaginary line drawn from theouter canthus of the eye to the
occiput with no swelling orthickening. Cerumen should bemoist and not obscure thelympanic membrane. There shouldbe no foreign bodies, redness,drainage, deformities, nodules orlesions.
They should feel firm (not tender)and movement produce pain.
The patient should be able torepeat words whispered from adistance of 2 feet.
Measures hearing by airconduction (AC) or by boneconduction (BC), in which thesound vibrates through the cranialbones to the inner ear.
The patient should perceive thesound equally in both ears or inthe middle. No lateralization ofsound is known as negativeWebster test.Air conduction is heard twice as
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NeckInspection:For symmetry of thesternocleidomastoid musclesanteriorly, and the trapeziusposteriorly.
Palpation:For the presence of masses andtenderness.
Lymph NodesInspection:For any enlargement or
inflammation.
Palpation:For size, shape, dellimination,mobility, consistency, andtenderness
Trachea
Palpation:
Thyroid GlandInspection:For symmetry and visible masses.
long a bone conduction when thepatient hears the sound throughthe external auditory canal ( air )after it is no longer heard at themastoid process ( bone ). This is
denoted as AC>BC.
The muscles of the neck aresymmetrical with the head at acentral position. The patient isable to move head through a fullrange of motion without complaintof discomfort or noticeable
limitation. The patient may bebreathing through a stoma ortracheostomy.
The muscles are symmetricalwithout palpable masses orspasm.
Lymph nodes should not be visibleor inflamed.
Normally, lymph nodes should notbe palpable in the healthy adultpatient; however, small, discrete,movable nodes are sometimespresent but are of no significance.
Space should be systemic on bothsides or on central placement inmidline of neck; spaces are equalon both sides.
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Palpation:
For nodules or enlargement andtenderness.
ThoraxChest AnteriorInspection: For the breathingpatterns, rate, depth, the coastalangle, shape of patients chest,and color.
Palpation:For respiratory excursion.
Tenderness, masses andtemperature.
Percussion:For its different sound
Auscultation:For full two breaths and sounds
Lungs
Thyroid tissue moves up withswallowing but often themovement is so small it is notvisible on inspection. In males, thethyroid cartilage, or Dms apple, is
more prominent than in females.
No enlargement, masses, ortenderness should be noted onpalpation.
Quiet, rhythmic, and effortlessrespirations. Breathing patternshould be smooth. Costal angle isless than 90, and the ribs insert
into the spine at approximately a45 angle. Normal rate ofbreathing in adult is 46/16 permin. red patches present, ribssloping downward with symmetricinterspaces. Colors should be evenand consistent with the color ofthe patients face. Shoulder shouldbe at the same height. shape ofthorax elliptical shape
It should be full symmetricexcursion; thumbs normallyseparate to 3-5 cm (1 to 2in). Equal expansion, notenderness, no masses, skinshould be warm and dry, nopulsation should be present.Fremitus is normally decreasedover heart and breast tissue.
Normal lung tissue-resonantsound, rib flat sound.
Air brushing through therespiratory tract during inspirationexpiration generates differentbreath sounds.
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Inspection:For breath sounds over thefollowing:Trachea
Alveolar Tube (large-stem bronchi)
Lung Field (lung periphery)
HeartPalpation:
Auscultation:For murmurs and sound
Chest Posterior
Inspection:For shape and symmetry, spinalalignment for deformities, color,abnormal inspiratory.
Palpation:For clients who have norespiratory complaints,
temperature.For clients who have respiratorycomplaints.For respiratory excursion
Bronchial (loud, tubular) breathsounds heard over trachea;
expiration longer than inspiration;short silence between inspirationand expiration.
Bronchovesicular breath soundheard over main stem bronchi:below clavicles and betweenscapulae (inspiratory phase equalto expiatory phase).
Vesicular (low, soft, breezy) breathsounds heard over lung periphery(inspiration longer thanexpiration).
No pulsation palpable over aorticand pulmonic areas.
Apical has the loudest sound; itshould be 60-80 beats/min. No
murmurs should be heard.
Anteroposterior to transversediameter in ratio of 1.2; chestsymmetric; spine column verticallyaligned. No patches, no abnormalinspiratory retraction ofinterspaces.
The skin should be intact; uniformtemperature.
The chest wall intact; uniformtemperature.Full and symmetric chest
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For vocal and tactile fremitus
Percussion:For sounds
For diaphragm excursion
Auscultation:For sounds
AbdomenInspection:-Color
-Scars
-Striae
-Dilated Veins
-Rashes and lesions-Umbilicus
expansion. [Ex. When the clienttakes a deep breath, your thumbsshould be move apart an equaldistance and at the same time;normally the thumbs separate 3 to
5 cm (1 to 2 in.) during deeppalpation].
Bilateral symmetry of vocalfremitus. Fremitus is heard mostclearly at the apex of the lungs.Low-pitched voices of males aremore readily palpated than higherpitched voices of females.
Percussion notes resonate exceptover scapula.
Lowest point of resonance is at thediaphragm. (Note: percussion on arib normally elicits dullness)
Excursion is 3-5 cm (1 to 2 in.)bilaterally in women and 5-6 (2 to3 in.) in men. Diaphragm is usually
slightly higher on the right side.Vesicular and bronchovesicularbreathe sounds.
-Surface is uniform in color and inpigmentation.-Flawless no scars is present. Ifscars are present draw its locationin the persons record indicating
the length in cm.-No striae / stretch marks arepresent.-A few small veins may be visiblenormally.-No rashes or lesions are present.-Is normally in the midline andinverted with no sign of
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-The contour of the abdomen
-Hair distribution
-Symmetry-Respiratory movement
Auscultation:Auscultate the four quadrants forbasic sounds.Auscultate over the aorta, renal,iliac and femoral arteries.(Vascular sounds)
Percussion:Percuss the four quadrants to astympany and dullness.
Right Upper Quadrant:- liver- gallbladder
- duodenum- head of pancreas- right kidney and adrenal- hepatic flexure of colon- Part of ascending and transversecolon
Right Lower Quadrant:-Cecum-Appendix-Right ovary and tube
-Right ureter-Right spermatic cord
Midline:-Aorta-Uterus(if enlarged)-bladder(if enlarged)
inflammation, discoloration orhernia.-Normally range from flat torounded.-Diamond shape in adult males,
inverted triangular shape in adultfemale.-Symmetric bilaterally andsmooth.-The abdomen rises withinspiration and falls withexpiration.
High pitched, irregular gurgles (5-35 times/ min) present equally in
all four quadrants. No bruits, novenous hums, no friction.
Tympany is usually predominatingbecause of air in the stomach andintestines. Dull sounds are heardover solid masses such as liver,spleen, and kidneys.
Left Upper Quadrant:- stomach- spleen- left lobe of liver- body of pancreas- left kidney and adrenal- spleen flexure of colon- part of transverse & descendingcolon
Left Lower Quadrant:
-Part of descending colon-Sigmoid colon-Left ovary and tube-Left ureter-Left spermatic cord
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Palpation:Perform palpation to judge thesize, location and consistency ofcertain organs and to screen foran abnormal mass or tenderness.
Light Palpation (1/2 - 1 inch) on allareas of abdomen movingclockwise and in rotary motion.
Deep Palpation (2-3 inches) on allareas on the abdomen movingclockwise and in rotary motion.
Liver Palpation:Located in the RUQ (Right Upper
Quadrant).Place your left handunder the persons back parallel tothe 11th and 12th ribs and lift upto support the abdominalcontents. Place your right hand onthe RUQ with fingers parallel tothe midline. Push deeply downand under the right costal marginthen ask the person to take adeep breath.
Hooking TechniqueAn alternative method ofpalpating the liver. Stand up atthe persons shoulder and swivelyour body to the right so that youface the persons feet. Hook yourfingers over the costal marginfrom above. Ask the person totake a deep breath then try to fellthe liver edge bump from yourfingertips.
Spleen Palpation:Search spleen by reaching yourleft hand over the abdomen andbehind the left side at the 11thand 12th ribs. Lift for support.Place your hand obliquely on theLUQ with the fingers pointing
Normally there is no pain,tenderness, rigidity and muscleguarding
Normally there is no pain,tenderness, rigidity and muscle
guarding
It feels like a firm rectangularridge. Often the liver is notpalpable and you feel nothingfirm.
Normally you should feel nothingfirm. When enlarged the spleenextends into the lower quadrants.
A person normally feels a thud butno pain.Sharp pain occurs withinflammation of kidneys or
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toward the left axilla and justinferior to the rib margin. Pushyour hand deeply down and underthe left costal margin and ask theperson to take a deep breath.
KidneyPercussion:Indirect fist percussion causes thetissues to vibrate instead ofproducing a sound. Locate kidneyby placing hand over the 12th ribat the costoverbral angle on theback. Thump that hand with theulnar edge of your other fist.
Palpation:locate kidney by placing yourhand together in a duck-billposition at the person;s rightflank. Press your two handstogether firmly (you need deeperpalpation than that used to liverand spleen) then ask the person totake a deep breath.
Palpation:
Light palpation in all 4 quadrantsDeep palpation in all 4 quadrants
ExtremitiesUpper and LowerInspection:-Observe for size, color, contour,symmetry and involuntarymovement
-Look for deformities, edema, andpresence of lesions.
- Always compare both extremities
Palpation:-Feel evenness of temperature.Normally it should be even for all
paranephric area.
Lower pole of the kidney is round,smooth mass slide in betweenyour fingers.
Both extremities are equal in size
Have the same contour withprominences of joints.
No involuntary movements. Noedema. Color is even.
Temperature is warm and even.
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the extremities.
- Perform range of motion
-Test for muscle strength
Has equal contraction.
Can perform complete range ofmotion
Can counter act gravity andresistance in ROM