HYSICAL ASSESSMENT/ EXAMINATION HEAD TO TOE

Prepared byT: Sanaa abdel hamed

2 OBJECTIVES By the end of the topic students should be able to:-

Define physical assessmentDescribe the four techniques used in physical assessmentKnow how to
do a head to toe assessment

3 .Physical assessment is a systematic data collection method that uses the senses of sight,
hearing, smell and touch to detect health problems. There are four techniques used in physical
assessment and these are:- Inspection, palpation, percussion and auscultation. Usually history
taking is completed before physical examination

4 InspectionIt’s the use of vision to distinguish the normal from the abnormal findings. Body parts
are inspected to identify color, shape, symmetry, movement, pulsation and texture.

5 Principals of inspection
Availability of adequate lightPosition and expose body part to view all surfacesInspect each area for
size, shape, color, symmetry, Position and abnormalities.If possible compare each area inspected
with the same area on the opposite side.Use additional light to inspect body cavities

6 PalpationIt involves use of hands to touch body parts for data collection. The EMT uses fingertips
and palms to determine the size, shape, and configuration of underlying body structure and pulsation
of blood vessels. It help to detect the outline of organs such as thyroid, spleen or liver and mobility of
masses. It detects body temperature, moisture, turgor, texture, tenderness, thickness, and
distention.

7 Principles of palpation
Help client to relax and be comfortable because muscle tension impairs effective assessment.Advise
client to take slow deep breaths during palpationPalpate tender areas last and note nonverbal signs
of discomfort.Rub hands to warm them, have short fingernails and use gentle touch

8 PercussionIt is the technique in which one or both hands are used to strike the body surface to
produce a sound called percussion note that travels through body tissue. The character of the sound
determines the location, size and density of underlying structure to verify abnormalities. An abnormal
sound suggest a mass or substance like air, fluid in an organ or cavity.

9 AuscultationIt involves listening to sounds and a stethoscope is mostly used. Various body
systems like cardiovascular, respiratory and gastrointestinal have characterized sounds. Bowel,
breath, heart and blood movement sounds are heard using the stethoscope. It is important to know
the normal sound to distinguish from abnormal.

10 Preparation for physical exam

Infection prevention Follow IP precaution through out procedure Environment P/A requires privacy
and away from other destructors throughout Equipment Get all the necessary equipment, other
equipment needs to be warmed before being placed on the body e.g. rubbing diaphragm of the
stethoscope briskly between hands.
11 Preparation cont…Patient preparation Prepare the patient physically and make the patient
comfortable throughout the physical assessment for successful exam. Explain to the patient
everything to be done.

12 HEAD TO TOE ASSESSMENTGeneral survey The assessment of the patient/client begins on

the first contact. It includes apparent state of health , level of consciousness, and signs of distress.
The general height, weight, and build can be noted including skin color, dressing, grooming,
personal hygiene, facial expression, gait, odor, posture and motor activity.

13 NOTE:If there is a sign of acute distress comprehensive health assessment is deferred until
when patient is stable.

14 Vital signsAssessment of vital signs is the first in physical assessment because positioning and
moving the client during examination interferes with obtaining accurate results. Specific vital signs
can be also obtained during assessment of individual body system.

15 Skin, Hair, scalp and Nails

Inspect all skin surfaces first or gradually while assessing the systems. Use the skills of inspection,
palpation, and olfactory to assess the function. Skin Inspect skin for color, edema, lesions, scars and
vascularity. Palpate to notice moisture, temperature, and skin turgor,

16 Hair and scalpAssess and note type of hair i.e. long, coarse, thick, brittle. Note the color,
distribution, quantity, thickness, texture and lubrication. On inspection separate the hair to determine
the scalp. Wear clean gloves if lesions and lice are probable.

17 NailsThe condition of the nails reflects the general health, state of nutrition, occupation, and
level of self care. Nail biting can reveal the person’s psychological state. Inspect the nail bed for
color, cleanliness, length, texture, angle between nail and nail bed and folds around the nail. Palpate
the nail for inflamation

18 Head and neckThe assessment of the head includes:- eyes, ears, nose, mouth and pharynx.
The assessment of the neck includes:- lymph nodes, carotid artery, thyroid gland and trachea.

19 Eyes , EarsAssess visual acuity, position and alignment of the eyes, eyebrows and eyelids. Note
any abnormal discharges and color of conjunctiva and sclera. It determines the intergrity of the ear
structures and hearing acuity. Inspect for sore and discharges

20 Nose and sinusesAssess the integrity of the nose and sinuses by using inspection and
palpation. Nose Observe for shape, size, skin color, and presence of deformity or inflammation.
Sinuses The exam involves palpation. Incase of allergy or infection the inside is inflamed and
swollen so palpate for tenderness

21 Mouth and pharynxAssess mouth and pharynx to determine overall health and hygiene. Use pen
light and tongue depressor to assess oral cavity. Lips Inspect lips for color, texture, hydration,
contour, sores and lesions.

22 Buccal mucosa, gums, and teeth

Ask client to clench teeth and smile to observe to observe teeth occlusion, symmetry. A symmetrical
smile shows normal nerve function. Inspect teeth for hygiene, position, and alignment. Let client
open with lips relaxed, use tongue depressor to inspect the mucosa for color, moisture and sores.
Inspect gums for color, edema, retraction, bleeding and lesions.

23 Tongue and floor of mouth

Carefully inspect tongue on all sides as well as floor of mouth for color, size, position, texture,
moisture sores and lesions. Palate Have client extend the head backwards, holding the mouth open,
inspect the hard and soft palate for color, shape, texture and extra bonny prominences or defects.

24 PharynxLet the client tip the head back slightly, open mouth wide and say “Ah”, with penlight
inspect the uvula and soft palate, they should rise centrally as the client say “Ah” to determine the
function of cranial( vagus ) nerve function. Check the uvula and tonsils for redness and inflammation.

25 NeckPalpate the muscles, lymph nodes, carotid artery jugular veins for tenderness and
distention. Thyroid gland Ask client to hyperextend the neck and view the thyroid and palpate for
masses. Normally thyroid gland is not visible.

26 ChestInspect the skin for scars, sores, color, lesions, chest, movement and respiratory rate.
Palpate to notice any masses, and tenderness in axillae and breast. Lungs Auscultate to assess
respiratory and sounds from the lungs and chest cavity. Percussion is done to detect accumulation
of fluid or air in the chest cavity.

27 HeartAuscultate to hear the heart sound. Learn to know the normal heart sound to be able to
detect the abnormal Breast Inspect the breast for skin color, scars and lesions. Palpate to notice any
presence of masses.

28 ExtremitiesUpper and lower extremities Inspect hand and legs for symmetry, alignment, skin
color, temperature, sores, scars, lesions inflammation and varicosity. Palpate for tenderness, edema
and pulsation of arteries. Use the brachial, radial, ulna, femoral, popliteal, posterior tibia and dorsalis
pedis pulses. Check capillary refill on nails, clubbed toes /fingers and joint mobility.

29 Deep tendon reflexesNormally done on high risk patients and needs specialized practice and
special hammer to assess the reflexes. Areas that are assessed are on biceps, triceps, patella, and
Achilles.

30 AbdomenInspect the skin for color, sores, lesions, scars, position of umbilicus, distention and
contours. Palpate for tenderness, masses and enlargement of other organs like liver, spleen and
kidney. Ask for bowel and bladder elimination. Percussion is used to detect the location of organs
that are normally palpable e.g. liver, spleen and intestines. Always auscultate before palpation or
percussion because touching can alter mobility of bowel and increase sound.

31 GenitaliaStart assessment of genitalia with asking questions and do inspection to confirm a

positive answer. Female Ask about presence of abnormal discharge, sores, warts and itching Male
Ask any presence of sores, itching, warts and abnormal discharge.

32 Rectum and anusInspect for the skin color, sores, hemorrhoids and lesions. Do digital palpation
to examine the anal canal for masses and sphincters function only when important.
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CONTENTS
CLINICAL PROCEDURES FOR SAFER
PATIENT CARE
Chapter 2. Patient Assessment

2.5 Head-to-Toe Assessment

A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each
shift, and when it is determined to be necessary by the patient’s hemodynamic status and the
context. The head-to-toe assessment includes all the body systems, and the findings will inform
the health care professional on the patient’s overall condition. Any unusual findings should be
followed up with a focused assessment specific to the affected body system.

A physical examination involves collecting objective data using the techniques of inspection,
palpation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17
outlines the steps to take.

Checklist 17: Head-to-Toe Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill

Safety considerations:

 Perform hand hygiene.

 Check room for contact precautions.
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g., name and date of birth).
 Explain process to patient.
 Be organized and systematic in your assessment.
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure patient’s privacy and dignity.
 Assess ABCCS (airway, breathing, circulation, consciousness, safety)/suction/oxygen/safety.
 Apply principles of asepsis and safety.
 Check vital signs.
 Complete necessary focused assessments.

Steps Additional Information

Alterations may reflect neurologic impairment, oral i

impairment, improperly fitting dentures, differences
language, or potential mental illness. Unusual findin
followed up with a focused neurological system asses
1. General appearance:

 Affect/behaviour/anxiety
 Level of hygiene
 Body position
 Patient mobility
 Speech pattern and articulation

Assess general appearance

This is not a specific step. Evaluating the skin,
hair, and nails is an ongoing element of a full
body assessment as you work through steps 3-
9.
2. Skin, hair, and nails:
 Inspect for lesions, bruising, and rashes.
 Palpate skin for temperature, moisture, and texture.
Check for and follow up on the presence of lesions, b
rashes.Variations in skin temperature, texture, and p
dehydration may indicate underlying conditions.
Redness of the skin at pressure areas such as heels, e
and hips indicates the need to reassess patient’s need
changes.
Unilateral edema may indicate a local or peripheral c
 bilateral-pitting edema usually indicates cardiac or k
 Inspect for pressure areas.
 Inspect skin for edema. Check hair for the presence of lice and/or nits (eggs)
shape and adhere to the hair shaft.
 Inspect scalp for lesions and hair and scalp for presence
of lice and/or nits.
 Inspect nails for consistency, colour, and capillary
refill.

Check eyes for drainage, pupil size, and reaction to li

indicate infection, allergy, or injury.

Slow pupillary reaction to light or unequal reactions

indicate neurological impairment.

3. Head and neck:

 Inspect eyes for drainage.

 Inspect eyes for pupillary reaction to light.
 Inspect mouth, tongue, and teeth for moisture, colour,
dentures.
 Inspect for facial symmetry.

Check pupillary reaction to light

Dry mucous membranes indicate decreased hydratio

Facial asymmetry may indicate neurological impairm

injury. Unusual findings should be followed up with
neurological system assessment.

4. Chest: Chest expansion may be asymmetrical with condition

atelectasis, pneumonia, fractured ribs, or pneumotho
 Inspect:
Use of accessory muscles may indicate acute airway o
o Expansion/retraction of chest wall/work of breathing
massive atelectasis.
and/or accessory muscle use
o Jugular distension Jugular distension of more than 3 cm above the stern
patient is at 45º may indicate cardiac failure.
 Auscultate:
o For breath sounds anteriorly and posteriorly The presence of crackles or wheezing must be furthe
o Apices and bases for any adventitious sounds documented, and reported. Unusual findings should
with a focused respiratory assessment.
o Apical heart rate
 Palpate:
o For symmetrical lung expansion

Auscultate anterior chest; blue dots indicate stethosc

auscultation

Auscultate posterior chest; blue dots indicate stethos

auscultation

Auscultate apical pulse at the fifth intercostal space a

line

Note the heart rate and rhythm, identify S1 and S2, a

any unusual findings with a focused cardiovascular a
 Abdominal distension may indicate ascites associate
such as heart failure, cirrhosis, and pancreatitis. Mar
peristalsis with abdominal distension may indicate in
obstruction.

Hyperactive bowel sounds may indicate bowel obstru

gastroenteritis, or subsiding paralytic ileum.

Hypoactive or absent bowel sounds may be present a

surgery, or with peritonitis or paralytic ileus.

Pain and tenderness may indicate underlying inflam

such as peritonitis.

Unusual findings in urine output may indicate comp

function. Follow up with a focused gastrointestinal a
assessment.
5. Abdomen:
Unusual findings with bowel movements should be f
a focused gastrointestinal and genitourinary assessm
 Inspect:
o Abdomen for distension, asymmetry
 Auscultate:
o Bowel sounds (RLQ)
 Palpate:
o Four quadrants for pain and bladder/bowel distension
(light palpation only)
 Check urine output for frequency, colour, odour.
 Determine frequency and type of bowel movements.

Auscultate abdomen

Palpate abdomen
 Limitation in range of movement may indicate articu
injury.

Palpate pulses for symmetry in rate and rhythm. Asy

indicate cardiovascular conditions or post-surgical co

Unequal handgrip and/or foot strength may indicate

conditions, injury, or post-surgical complications.

CWMS: colour, warmth, movement, and sensation o

feet should be checked and compared to determine a
perfusion.

6. Extremities: Check skin integrity and pressure areas, and ensure f

depth assessment of patient mobility and need for re
 Inspect: position.
o Arms and legs for pain, deformity, edema, pressure
areas, bruises
o Compare bilaterally
 Palpate:
o Radial pulses
o Pedal pulses: dorsalis pedis and posterior tibial
o CWMS and capillary refill (hands and feet)
 Assess handgrip strength and equality.
 Assess dorsiflex and plantarflex feet against resistance
(note strength and equality).
Assess plantar flexion
 Check skin integrity and pressure areas.

Assess dorsiflexion
Assess CWMS – colour, warmth, movement, and sen

Assess bilateral hand strength

Palpate and inspect capillary refill and report if more

Assess pedal pulses

 Check capillary refill

To check capillary refill, depress the nail edge to caus

then release. Colour should return to the nail instant
seconds. If it takes longer, this suggests decreased pe
and may indicate cardiovascular or respiratory
dysfunction. Unusual findings should be followed up
cardiovascular assessment.

Clubbing of nails, in which the nails present as stra

degrees, with the nail base feeling spongy, occurs wit
emphysema, and chronic bronchitis.

7. Back area (turn patient to side or ask to sit up or lean Check for curvature or abnormalities in the spine.
forward):
Check skin integrity and pressure areas, and ensure f
 Inspect back and spine. depth assessment of patient mobility and need for re
 Inspect coccyx/buttocks. position.

8. Tubes, drains, dressings, and IVs:

 Inspect for drainage, position, and function. Note amount, colour, and consistency of drainage (e.
or if infusing as prescribed (e.g., intravenous).
 Assess wounds for unusual drainage.
 Urinary catheter bag

Assess wounds for large amounts of drainage or for p

and provide wound care as indicated.

Assess patient’s risk for falls. Document and follow u

falls risk. Note use of mobility aids and ensure they a
patient on ambulation.

9. Mobility:

 Check if full or partial weight-bearing.

 Determine gait/balance.
 Determine need for and use of assistive devices.

Patient position prior to standing

10. Report and document assessment findings and Accurate and timely documentation and reporting pr
related health problems according to agency policy. safety.
 Data source: Assessment Skill Checklists, 2014; Jarvis et al., 2014; Stephen et al., 2012

Critical Thinking Exercises

1. You are assessing a patient at the beginning of your shift. Which assessment would be
the most appropriate?
2. You come back from a break to find your patient complaining that she feels short of
breath. Which assessment would be the most appropriate?

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2.5 Head-to-Toe Assessment by British Columbia Institute of Technology (BCIT) is

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