Head-to-Toe Assessment General Appearance: Patient appears conscious and coherent alert and oriented to time, place

and person lethargic and weak in appearance needs assistance to move and ambulate pale in appearance Area Assessed Normal Findings Actual Findings Analysis 1. Skull A. Inspects skull for &ounded &ounded 'normocephalic( Normal 1. si e 'normocephalic( symmetrical with $rontal, !. shape symmetrical with parietal, and occipital ". symmetry $rontal, parietal, prominences: smooth skull and occipital contour) #. Palpates $or prominences: tenderness o$ smooth skull mass%nodules, contour) depressions and No mass%nodules, tenderness depressions and tenderness Normal No mass%nodules, depressions and tenderness 2. Hair and Scalp A. Inspects for 1. *olor o$ +calp !. ,dor ". Presence o$ dandru$$ in$ection -. .esions B. Inspects for 1. *olor o$ /air !. 0istribution ". 1hickness% 1hinness -. 1e2ture 3. ,iliness 4. Presence o$ lice, nits, split ends 5. .ength 3. Face A. Inspects for 1. *olor o$ 8

6venly distributed +ilky, resilient hair '7) in$ection '7) in$estations

1he hair are une9ually distributed with thin hair strands: well kept:

Normal

Normal No lice or dandru$$ seen or noted.

+ymmetric% +lightly

+lightly pale in color

Abnormal 0ue to low hemoglobin

Eyes A. .+kin !. Normal 1he eyelashes are e9ually distributed and slightly curled outward. with no discharge or discoloration on the eyelids. and upper and lower borders o$ cornea slightly covered +kin intact '7) discharge . +hape%*ontour asymmetric $acial $eatures Palpebral $issures e9ual in si e +ymmetric nasolabial $old +ymmetric% +lightly asymmetric $acial $eatures Palpebral $issures e9ual in si e +ymmetric nasolabial $old '. no visible sclera above corneas. 0istribution !. Inspects the eyebrows for 1. 1e2ture -. no visible sclera above corneas. Inspects the eyelids for 1. hair distribution and alignment /air evenly distributed +kin intact 6yebrows symmetrically aligned 8 1he eyelashes are e9ually distributed and slightly curled outward. 0irection o$ curl C. color !. +ur$ace *haracteristics !. Position in relation to corner ". 4.ids close symmetrically 137!< involuntary blinks%min #ilateral blinking =hen lids open .ower lids when eyes closed -. Ability to blink and $re9uency +kin intact '7) discharge . and upper and lower borders o$ cornea slightly covered 1here is blinking re$le2 when sudden light appears and when touch Normal . +ymmetry ". Normal B.) rooting re$le2 when stroked near the cheek count Normal Normal Normal . Inspects the eyelashes for 1.

Inspects the pupils for 1. lesions -. Inspects the cornea for 1. edema !. Inspects conjunctiva for 1. 1here is also no evidence o$ tearing. Palpebral con>unctiva is shiny. Palpates lacri al !land and nasolacri al duct for 1. No edema or tenderness over lacrimal gland No edema or tearing Pupils constrict when looking near ob>ect Pupils dilate when looking at $ar ob>ect #lack 69ual in si e Normally "75 mm &ound +mooth #order @ris $lat and round @lluminated pupil Normal Normal Normal . smooth and pink or red. shiny. shiny. te2ture ". 1he pupils are black round and e9ual in si e and are reactive to light accommodation Normal 1he cornea is transparent. transparency -. 1ransparent. $oreign bodies #ulbar con>unctiva is transparent: capillaries sometimes evident +clera appears white ?ellowish in dark7 skinned. clarity !. direct and consensual reaction to light 1he lacrimal gland and nasolacrimal duct o$ the client when palpated were not tender. symmetry o$ si e -. color !. depth F. Normal E.Pale con>unctiva Abnormal 0ue to low hemoglobin count D. and smooth 0etails o$ the iris are visible Normal 1he pupils o$ my client are black in color. evidence o$ tearing ". e9ual in si e. te2ture ". shape ". and round. and smooth. color !.

shape !. pus or blood +ymmetric and straight No discharge or $laring Cni$orm color 1he ears are symmetrically aligned and the color is same as the $acial skin.A) 5. $laring 3. te2ture !. wet cerumen in various shades o$ brown No skin lesions. areas o$ tenderness C. color -. @t is the same color with the $ace. si e ".ight and AccommodationAP 6&&. pus or blood 6. and not tender Pinna recoils a$ter it is $olded 0ry cerumen. ose and Sinuses A. Inspects auricles for 1. no discharges. grayish7tan color: or sticky. $irm. Ears A. discharges 1he nose is symmetrically aligned with the $ace. elasticity ". Normal No serum and discharges noted. position B. Inspects e#ternal nose for 1. color !. cerumen !. Normal @t is not tender and no .constricts Non illuminated pupil constricts Pupils constrict when looking near ob>ect Pupils dilate when looking at $ar ob>ect 'Pupils 69ually &ound and &eactive to . blood *olor same as $acial skin +ymmetrical Auricle aligned with outer canthus o$ eye. Inspects e#ternal ear canal for 1. symmetry o$ si e ". pus. No skin lesions. skin lesions. Palpates for 1. about 1< degrees $rom vertical Bobile. @t is $irm and not tender.

watery discharge No lesions Not tender Nasal septum intact and in the middle Normal 1he mucosa is pink. 1he client possesses pink gums with a number o$ teeth only. nares !. position ". sur$ace !. color !. te2ture o$ gums C. has a $irm te2ture and no retraction o$ gums. te2ture -. Deter ine patency of nasal cavities D. 1he tongue moves $reely and not tender. Abnormal 0ue to inade9uate hemologlobin count Normal Pink gums Boist. te2ture -. Inspects the ton!ue for 1. presence o$ lesion B. color ". moisture ". Normal No tenderness: no lesions Air moves $reely as the client breathes through the nares Nasal septum intact and in the middle Bucosa pink *lear. Palpates for 1. Normal 1he sinuses are not tender when palpated. Normal Abnormal @ndicates dehydration or thirst 1he tongue o$ the client is . $irm gum te2ture '7) retraction o$ gums *lient has complete set o$ yellowish teeth 1he gums are slightly pink. moist. dry. redness% swelling E. No ulcerations or lesions noted. Inspects and palpates lips and buccal ucosa for 1.B. condition !. "out# and $rop#aryn% A. Palpates a#illary and frontal sinuses for 1. Inspects the !u s for 1. tenderness lesions present. Inspects for linin! of the 1. nasal septum ". movement Cni$orm pink color Pale Bucous Bembranes +o$t. smooth te2ture +ymmetric o$ contour . !. masses C. areas o$ tenderness.

Inspects hard and soft palate for 1. smooth palate . color !. pink in color. Normal *entral position Pink color +mooth lateral margins '7) lesions Boves $reely +mooth tongue base with prominent veins Normal Normal 1he smooth palate is light pink and the hard palate is lighter than the smooth. 1he uvula o$ the client is in the midline o$ the so$t palate. te2ture E. no lesions and can move $reely. shape ".ighter pink hard palate. F. more irregular in te2ture Cvula in midline o$ so$t palate Area Assessed ormal Findin&s Actual Findin&s Analysis .in central position. 1here are no palpable nodules but the tongue is smooth. +mooth with no palpable nodules .ight pink. color !. te2ture 1here are evidence o$ prominent veins on the smooth mouth $loor . Inspects the outh floor and roof for 1. Palpates ton!ue for nodules$ lu ps or e#coriated areas. D.

+moothness b. Normal Normal Normal *lient has ratio o$ 1:! in anteroposterior to transverse diameter: she has also a pigeon type o$ chest symmetric.obes are not palpable. )osterior T#ora% Inspect posterior thora# to for a. +pine is vertically aligned with evident curves in cervical and Normal Normal . Areas o$ enlargement. /ead $le2es -3D /ead hypere2tend 4<D /ead laterally $le2es -3D /ead laterally rotates 5<D Palpates the ly ph nodes for enlar!e ent. Palpates trachea for any lateral deviations.obes may not be palpated. +ymmetry Inspect the spinal ali!n ent for defor ities Not palpable *entral placement in midline: spaces are e9ual in both sides. eck Inspect the neck uscles for a. Anteroposterior to transverse diameter is 1:! ratio *hest symmetric +pine vertically aligned. centrally located. and painless and rise $reely with swallowing. (. Normal *oordinate. lobes are small. smooth. Palpates the thyroid !land for a. . masses or nodules. +hape b. smooth smooth movements movements with no with no discom$ort. @t is in the center o$ the neck and the spaces are e9ual in both sides. /ead movement Buscles e9ual in si e: head centered. +welling or masses b. 1here are no palpable nodes on client neck. . discom$ort.'. @$ palpated. *oordinate. *lientEs head is centered.

*hest e2cursion d. 1ympanic Auscultate the chest for breath sounds. Normal Cni$orm Cni$orm temperature. *ostal angle is H I<D. Anterior T#ora% Inspect the anterior thora# for a. 1horacic c. &esonant b. 1emperature and integrity b. Normal Normal No adventitious sounds 1*. and & shoulders are in the same height. *lientEs temperature is uni$orm.a. *oastal angle and the angle at which ribs enter the spine Palpates the Guiet rhythmic and Normal && e$$ortless respiration. #ronchial &esonance e2cept over scapula 0ullness over ribs Flat over bone or muscle 1ympanic over stomach. & and . 1here are no lumps. abnormal movements c. masses areas o$ tenderness Normal &esonance e2cept over scapula 0ullness over ribs Flat over bone or muscle 1ympanic over stomach. when she inhales. Areas o$ tenderness. #roncho7vesicular. . &ibs insert into spine at -3D angle. Fesicular. masses areas o$ tenderness lumbar spine. +kin is intact same as chest wall. #reathing patterns b.umbar Palpates the posterior thora# for a. +pinal column straight. *ervical b. 0ull d. Focal 'tactile) $remitus Percuss the thora# and identifies percussion notes a. Flat c. bulges. Normal . shoulders and hips at the same height Cni$orm temperature +kin intact *hest wall intact No lumps. . By thumb moves or separate about "73 cm.

+kin intact. masses areas o$ tenderness. Flat c. Heart+ .anterior chest for a. 1emperature. integrity o$ skin b. +kin intact. 1ympanic temperature. masses areas o$ tenderness. bulges. No lumps. No lumps. *hest wall intact. *hest e2cursion d. Areas o$ tenderness. 1actile 'vocal ) $remitus 'male only) Percuss the anterior chest a. #ilateral symmetry o$ vocal $remitus. #ilateral symmetry o$ vocal $remitus. 0ull d. *hest wall intact. '. 1rachea b.eins .arotid Arteries+ -u&ular . &esonant b. #reath sounds &esonance down to 4th rib J diaphragm level Flat over heavy muscles and bone 0ull over the heart and the liver 1ympanic over underlying stomach #ronchial breath sounds #ronchovesicular and vesicular breath sounds &esonance down to 4th rib J diaphragm level Flat over heavy muscles and bone 0ull over the heart and the liver 1ympanic over underlying stomach Normal Normal No adventitious sounds 11.) retractions Normal Auscultate the a. abnormal movements c.

Apical 'Bitral) Palpates the carotid artery +17 all sites. Apical e. changes sitting to supine 6lastic arterial wall Normal Normal . Pulmonic c. thrusting 9uality Guality remains the same when ct breathes. thrusting 9uality Guality remains the same when ct breathes. esp base o$ the heart +"7 in children% young adults +-7 older adults +ymmetric pulse volume Full pulsation. No li$ts or heaves Aortic pulsations Auscultates the heart in all four sites% Aortic.@*+ B*. No li$ts or heaves Aortic pulsations No pulsation No li$ts or heaves Pulsation visible in 3<K adults Palpable in most PB@ in 3th . Aortic b. turn head. 1ricuspid. turn head. Pulmonic. esp at apical +!7 all sites.@*+ B*. 1ricuspid d. changes sitting to supine 6lastic arterial wall +17 all sites. esp base o$ the heart +"7 in children% young adults +-7 older adults +ymmetric pulse volume Full pulsation. esp at apical +!7 all sites.Inspect and Palpates the followin! areas a. 6pigastric $or pulsation No pulsation No pulsation Normal No pulsation No li$ts or heaves Pulsation visible in 3<K adults Palpable in most PB@ in 3th .

+i e b. Any discoloration %hyperpigme ntation d. Normal No tenderness. *olor e. 1enderness. +welling or edema Palpates breasts for a. nipple discharge and nodules No tenderness. +hape%conto ur c. No swelling or edema No tenderness and discharge +kin uni$orm in color +kin smooth and intact 6ven with chest wall 1here is no presence o$ edema or swelling No tenderness and discharge Normal &ounded or oval .val bilaterally the bilaterally the same same *olor varies *olor is pink brown widely. +ur$ace characteristic s Palpates the areola and nipple for a. nipple discharge and nodules Normal . +i e b. +ymmetry d. Basses. 0ischarge o$ nipples Inspect the areola a. +hape%conto ur c. tenderness b. masses.Inspect the ju!ular vein for distention Fein is not visible Fein is not visible Normal 12. /reast and A%illae Inspect breasts for a. Presence o$ any discharge Normal +kin uni$orm in color +kin smooth and intact No swelling No discoloration%hyper pigmentation. masses. masses b. $rom light to pink brown.

*ontour%sha pe c.: 471! cm '!. Friction rubs Audible bowel sounds 'heard every 3 to !< seconds) "7!< #owel sounds% minute Absence o$ arterial bruits Absence o$ $riction rubs.: Lcm Bidsternal:. +kin integrity b.37" in.3 inches) Bidsternal: -7L cm.13. 1ympany over the stomach and gas7 $illed bowels: 0ullness over the liver and spleen. Abdominal movement in relation o$ respiration Cnblemished skin. &educed skin turgor 1second Normal Abnormal &educed skin turger due to diarrhea . consistent tension /yper active bowel sounds Abnormal @ndicates increased bowel activity Percusses the abdo en in each of the four &uadrants $or tympany and dullness Percusses the liver to deter ine si'e Perfor s li!ht palpation of the abdo en to detect areas of tenderness and Absence $or tympany and dullness Normal B*. Fascular sounds c. rela2ed abdomen with smooth. '1. #owel sounds b. A0domen Inspect the abdo en for a.) No tenderness.cm. +ymmetry d. &ounded 'conve2) or +caphoid 'concave) +ymmetric contour No evidence o$ spleen or liver enlargement 1he abdomen distended is Abnormal 0istended abdomen Bay indicate in$lammation%swelling or parasitic in$ections Auscultates abdo en for a. uni$orm color 'no lesion) +ilver7white striae 'stretch marks) or surgical scars Flat. or a $ull bladder B*.37".

#ony prominences c. the client is able to e2ecute the re$le2es. &otation 'internal. Fle2ion b. Moint structure e. $irm. 1here is no enlargement o$ liver Not palpable Abnormal Pain or discom$ort due to swelling or in$lammation in the abdomen Normal 69ual si e on both sides No swelling% tenderness No nodules or crepitation 69ual si e on both sides No swelling% tenderness No nodules or crepitation Normal (bserves the shoulder$ elbow$ wrist$ hand and fin!ers for ran!e of otion a. Buscle mass d. 1pper E%tremities Inspect the shoulder$ elbow$ wrist$ hand and fin!ers for a. #ony structure b. +ymmetry No tenderness. Normal Normal 1emperature is uni$orm 1emperature is uni$orm . Abduction d. no tenderness As observed. Adduction e. 62tension c. e2ternal) Palpates the elbow$ wrist$ hand and fin!ers for Bobile. consistent tension Bay not be palpable #orders $eel smooth Not palpable 1enderness in the lower 9uadrants Not palpable. rela2ed abdomen with smooth.uscle !uardin! Perfor deep palpation over all four &uadrants Palpates liver to detect enlar!e ent and tenderness Palpates the bladder for distension 14.

#ony landmarks b. no tenderness 1he client is able to e2ecute the $le2ion. Moint structure c. Buscle mass c. 62tension Palpates the hip for a. #one structures and #ony landmarks b. Buscle si e c. 2o3er E%tremities Inspect the hip$ knee$ ankle$ foot and toes for a. Fle2ion b. $irm.a. Moint structure d. Moint structure No swelling% tenderness No swelling% tenderness 69ual si e on both sides No swelling% tenderness No nodules or crepitation 69ual si e on both sides No swelling% tenderness No nodules or crepitation Normal (bserves the $ knee$ ankle$ foot and toes for a. #ony landmarks b. 1emperature 15. 1emperature Bobile. e2tension o$ $oot and toes Normal Normal 1emperature is uni$orm No swelling% tenderness 1emperature is uni$orm No swelling% tenderness .

Sign up to vote on this title
UsefulNot useful