Head to Toe Assessment
Head to toe assessment is a vital aspect of nursing. It should be done at the beginning of each shift. It is the first step to determine the health status of the patient and to gather the information because it gives a clear picture of a person’s health status. The entire plan of nursing care is based on the data you collect from head to toe assessment. Therefore a nurse should be expert enough for this procedure.
Assesment Procedure
The procedure for the head to toe assessment includes
- Inspection
- Palpation
- Percussion
- Auscultation
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Inspection
It includes the close and careful visualization of the person as a whole. It also includes each of the body systems.
Palpation
- Temperature, Texture, Moisture.
- Organ Size & Location.
- Rigidity or Spasticity.
- Crepitation & Vibration.
- Position & Size.
- Presence of lumps or masses.
- Tenderness or Pain.
Percussion
Assess underlying structures for location, size, the density of underlying tissues.
Auscultation
Listen to the sounds produced by the body.
Instrument: Stethoscope
- Diaphragm – high pitched sounds
- Heart
- Lungs
- Abdomen
- Blood vessels
Physical Assessment
General
- General health status
- Vital signs and weight
- Nutritional status
Mobility And Self-care
- Observe posture
- Assess gait and balance
- Evaluate mobility
- Activities of daily living
Head, Face & Neck
- Evaluate cognition
- LOC
- Orientation
- Mood
- Language
- Memory
- Sensory function
- Test Vision
- Inspect and examine the ear
- Test hearing
- Cranial nerves
- Inspect lymph modes
- Inspect neck veins
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Chest
- Inspect and palpate breast
- Inspect and auscultate lungs
- Auscultate heart
Abdomen
- Inspect, auscultate and palpate four quadrants of the abdomen.
- Palpate and percuss the
- Liver
- Stomach
- Bladder
- Bowel elimination
- Urinary elimination
Skin, Hairs, and Nails
- Inspect the scalp, hair & nails.
- Evaluate skin turgor.
- Observe the skin lesion.
- Assess wounds.
Genitalia
- Inspect female client
- Inspect male client
Extremities
- Palpate arterial pulses because it will help us understand pulse rate.
- Observe capillary refill
- Evaluate edema because it will help us understand conditions like electrolyte imbalance.
- Assess joint mobility and therefore understand the condition of the joints
- Measure strength because it is important to understand it.
- Assess sensory function to verify the functioning of the sensory and motor functions of the patient.
- Assess circulation movements and sensation, therefore, using different tests.
- Deep tendon reflexes because they are very important.
- Inspect skin and nails
Head to toe assessment
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