head to toe physical assessment

5/13/2018 Head to Toe Physical Assessment - slidepdf.com

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I. APPEARANCE AND MENTAL STATUS

A. Body built, height, and weight (in relation to

the client's age, lifestyle, and health)

Proportinate, varies with lifestyle

B. Posture and gait, standing, sitting, and

walking

Relaxed, erect posture, coordinated

movement

C. Overall hygiene and grooming Clean, neat

D. Body and Breath odor

No body odor or minor body odor

relative to work or exercise; no breath

odor

HEAD TO TOE PHYSICAL ASSES

NORMAL FINDINGS ACUTAAREA TO BE ASSESSED





2. Uniformity of skin color

Generally uniform except in areas

exposed to the sun; areas of llighter

pgmentation (palms, lips, nail beds) in

dark-skinned people

3. Presence of edema No edema

4. Existence of lesions

Freckles, some birthmarks, some flat

and raised nevi, no abrasions or other

lesions

5. Skin Moisture

Moisture in skin folds and the axillae

(varies with environmentaltemperature and humidity, body

temperature, and activity)

6 Skin temperature Uniform; within normal range





1. Size, shpae and symmetry of the skull

Rounded (normecephalic and

symmetrical, with frontal, parietal, and

occipital prominences); Smooth skull

contour

2. Presence of nodules, masses,

and depressions

B. HAIR

1. Evenness of growth, thickness orEvenly distributed and covers the

thinness of hairwhole scalp: Maybe thick or thin

C. FACE

Facial features, symmetry of facial movements

Symmetric or slightly asymmetric facial

features; palpebral fissures equal in

size; symmetric nasolabial folds

Smooth, uniform consistence; absence

of nodules or masses






Color and clarity

White in color, clear, no yellowish

discoloration; some capillaries maybe

visible

F. CORNEA

Clarity and textureNo irregularities on the surface; looks

smooth; clear or transarent

G. IRIS

Shape and color

Anterior chamber is transparent; no

noted visible materials; color depends

on the person's race






H. PUPILS

1. Color, shape, and symmetry of size

Color depends on the person's race;

size ranges from 3-7 mm, and are equal

in size; equally round

2. Light reaction and accommodation

Constrict briskly/sluggishly when light

is directed to the eye, both directly and

consensual

I. VISUAL ACUITY

1. Near vision Able to read newsprint

2. Distance vision 20' 20' vision on Snellen chart






L. VISUAL FIELDS

Peripheral visual fieldsWhen looking straight ahead, client can

see objects in the periphery

V. EARS

A. AURICLES

1. Color, symmetry of size, and position

Color same as facial skin; symmetrical;

auricle aligned with outer canthus of

eye, about 10 degrees from vertical

2. Texture, elasticity and areas of tendernessMobile, firm, and not tender, pinna

recoils after it is folded

B. HEARING ACUITY TESTS

1 Cli t ' t l i t N l i t dibl






4. Patency of both nasal cavitiesAir moves freely as the client breathes

through the nares

5. Tenderness, masses, and displacements of

bone and cartilageNot tender; no lesions

VII. SINUSES

Identification of the sinuses and for tenderness Not tender






VIII. MOUTH

A. LIPS

Symmetry of contour color and texture

Uniform pink color, soft, moist, smooth

texture; symmetry of contour, ability topurse lips

B. BUCCAL MUCOSA

Color, moisture, texture and the presence of

lesions

Uniform pink color, moist smooth, soft,

glistening, and elastic texture

C. TEETH

Color, number and condition and presence of dentures

32 adult teeth; smooth white, shinytooth enamel, smooth, intact dentures

D. GUMS






1. Color and texture Pink and smooth posterior wall

2. Size, color, and discharge of the tonsilsPink and smooth; no discharge; of

normal size

3. Gag reflex Present






IX. NECK and LYMPH NODES

A. NECK MUSCLES

Inspection of neck muscle and head

movement.

Muscles equal in size, coordinated head

movement without discomfort

A. LYMPH NODES

Identification of Lymph nodes and for

tendernessNot palpable

B. TRACHEA

Placement of the Trachea Central placement in midline of neck;spaces are equal on both sides

C. THYROID GLAND






6. Posterior thorax percussion

Percussion notes resonate except over

scapula; Lowest point of resonance is at

the diaphragm; percussion on a rib

normally elicits dullness

7. Posterior thorax auscultationVesicular and bronchovesicular breath

sounds

B. ANTERIOR THORAX

1. Breathing patternsQuiet, rhytmic, and effortless

respirations

2. Temperature, tenderness, massesSkin intact; uniform temperature; chest

wall intact; no tenderness; no masses






XI. CARDIOVASCULAR

A. AORTIC and PULMONIC AREAS No pulsations

B. TRICUSPID AREA No pulsations; no lift or heave

C. APICAL AREA

Pulsations visible in 50% of adults and

palpable in most PMI in fifth LICS at or

medial to MCL

D. EPIGASTRIC AREA Aortic pulsations






XII. CAROTID ARTERIES

1. Carotid artery palpation

Symmetric pulse volumes; full

pulsations, thrusting quality; quality

remains same when the client

breathes, turns head, and changes from

sitting to supine position; elastic

arterial wall

2. Carotid arteries auscultation No sound heard on auscultation

XIII. JUGULAR VEINS

Jugular veins inspection No sound heard on auscultation

XIV. BREAST and AXILLAE






3. Areola's size, shape, symmetry color,

discharge, and lesions

Round or oval and bilaterally the same;

color varies widely, from light pink to

dark brown; irregular placement of

sebaceous glands on the surface of the

areola irregular placement of sebaceous glands on the surface of the

areola

4. Nipple's size, shape, position, color,

discharge, and lesions

Round, everted, and equal in size;

similar in color; soft and smooth; both

nipples point in the same direction; no

discharge, except from pregnant or

breast-feeding females; inversion of

one or both nipples that is present from

puberty

5. Axillary, subclavicular, and supraclavicular

lymph nodesNo tenderness, masses, or nodules






6. Vascular pattern No visible vascular pattern

7. Bowel sounds, vascular sounds, and

peritoneal friction rubs

Audible bowel sounds; Absence of

arterial bruits; absence of friction rub

8. Several abdominal areas of the four

quadrants

Tympany over the stomach and gas-

filled bowels; dullness, especially over

the liver and spleen, or a full bladder

9. Light palpation in the four quadrantsNo tenderness; relaxed abdomen with

smooth, consistent tension

XVI. MUSCULOSKELETAL

SYSTEM






B. BONES

1. Normal structures and deformities in the

skeletonNo deformities

2. Areas of edema or tenderness in the bonesAbsence of edema or tenderness in

bones

C. JOINTS

1. Joint swelling No joint swelling, no warmth, redness

2. Tenderness, smoothness of movement,

swelling, crepitation and presence of nodules

No tenderness, swelling and nodules:

smooth movements: minimal crepitus

may be present but there should be no

pronounced crepitation

head to toe physical assessment

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