Procedure

Preparation

1. Assemble/gather equipment to the body system/region to be assessed 210

2. Greet /identify client 210

Good afternoon, Sir. I am Dareen Kaye Grio, a student nurse from Central
Philippine University. May I know your name please. May I see your wristband.
Thank you.

3. Explain the procedure to be done, the reason and how the client can 210
cooperate

Today I will be performing head to toe physical assessment. This is done to

collect a hollistic subjective and objective data to determine client’s overall level of
functioning. I would like to ask for your cooperation. Is it okay with you sir?

4. Perform hand hygiene and observe other appropriate infection control 210
precautions

I will wash my hands first.

5. Provide privacy

I will close the curtains to provide some privacy and is it okay if I will turn on the
lights? Thank you.

ASSESSMENT: GENERAL SURVEY

6. General appearance, facial expression, body built, height and weight in 210
relation to age/developmental stage
The patient’s general appearance and facial expression is normal. Body built is
appropriate for the height which is — and weight of – kgs.

7. Client’s posture/gait, hygiene/grooming, body/breath odor, signs of distress 210

Sir, how are you today? Can you please stand up straight and then walk to the
door and back, please. Thank you.

8. Apply gloves as necessary 210

7ygb

ASSESSMENT: HEAD

I am now going to assess the head

9. Inspect and palpate the head for size, shape and configuration 21 0

10. Note consistency, distribution and color of hair 21 0

11. Observe face for symmetry, facial features, expressions and skin condition 21 0

12. Palpate the temporal arteries for elasticity and tenderness 21 0

13. As client opens and closes mouth, palpate the temporo-mandibular joint 21 0
(TMJ) for tenderness, swelling and crepitation
Touch TMJ before asking the client to open and close their mouth. Then palpate
and ask if there is any pain felt.
Can you please open and close your mouth? Do you feel any pain, sir?

ASSESSMENT: EYES

I am now going to assess the eyes

14. Test visual acuity. Ask client to read smallest possible line of letters, first 21 0
with both eyes open and then one eye at a time
Here is an eye occluder to be used for later. But first, can you please read what is
written aloud, sir.
Now using the eye cover, pls cover your right eye first and then read again
covering the left eye.

15. Inspect external eye structure (eyelids, eyelashes, eyeballs, and eyebrows), 2 1 0
cornea, conjunctiva and sclera. Note color, edema, symmetry and alignment

Close ang eyes for eyelids .

Both eyes Retract lower eyelid and ask the patient to look up
Retract the upper eyelid and ask the patient to look down

16. Examine the pupils for equality of size, shape, reaction to light by darkening 2 1 0
the room and using a penlight to shine the lights on each pupil.

Turn off the lights. Penlight out going in

Please look towards me, sir.

ASSESSMENT: EARS

I am now going to assess the ears

17. Inspect the external ear bilaterally for shape, size and lesions, discoloration 210
and discharge

Up and back ang ears

18. Palpate the ear and mastoid process for tenderness 210

Do you feel any bpain, sir?

ASSESSMENT: NOSE AND SINUSES

I am now going to assess the noseand sinuses

19. Inspect the external nose for color, shape and consistency. Palpate external 2 1 0
nose for tenderness

Slight tanga ang patient

20. Check patency of airflow through nostrils (occlude one nostril externally with
a finger while the client breathes through the other; repeat for the other side
21 0
Occlude 1 nostril at a time.

Please, breathe in and breathe out.

ASSESSMENT: MOUTH AND THROAT

I am now going to assess the mouth and throat

 21. Perform hand hygiene and don gloves 21 0

Wear gloves

22. Inspect the lips for consistency, color and lesions 21 0

Use gauze and indi pagbuyan

Procedure

23. Inspect the teeth for number and condition 210

Can you please open your mouth? Thankyou

Use penlight

24. Check the gums and buccal mucosa for color, consistency, lesions 210

Use a tongue depressor

25. Inspect the hard and soft palate for color and integrity by asking the client to 210
open mouth wide using a tongue blade and penlight

26. Ask client to say “Aaah” and observe the rise of the uvula 210

Can you please say “Aaah”?

27. Inspect tonsils for color, size and exudates 210

28. Inspect the tongue for color, moisture, size and texture, Inspect frenulum and 210
Wharton’s duct

29. Palpate the tongue for masses and tenderness 210

Use the same gauze sa lips. Discard gloves.

ASSESSMENT: NECK

I am now going to assess the neck

30. Inspect the neck for lesions, masses, swelling 210

 31. Test range of motion 210

Can you please follow what I do.

ROM: up and down, left and right, rotation

32. Palpate lymph nodes in slow and circular motion 210

Lymph nodes:Preauricular, Posterior auricular, Occipital, Submental,

Submandibular, Tonsillar, Superficial cervical, Deep cervical, Posterior cervical,
Supraclavicular

Deep cervical face sideward kag palpate sa sulod.

Supraclavicular raise ang shoulders then palpate.

33. Palpate the trachea for alignment and deviation. Inspect the thyroid gland for 210
visible enlargement and masses

After palpating, Hyperextend neck and ask patient to swallow.

Please look at the ceiling and please swallow your saliva.

34. Inspect and palpate carotid arteries. Auscultate bruit 210

Use bell of the diaphragm to auscultate carotid arteries.

ASSESSMENT: ARMS, HANDS AND FINGERS

I am now going to assess the arms, hands, and fingers

35. Inspect the upper extremities for over-all skin coloration, texture, moisture, 210
masses and lesions

36. Palpate shoulders and arms for tenderness, swelling and temperature 210

37. Assess epitrochlear lymph nodes 210

38. Test ROM of shoulders and elbows 210

Can you please follow what I do.

ROM: flexion and extension, abduction and adduction, supination and pronation

Up, front, back, flex and extend

39. Palpate the brachial, ulnar and radial pulses 210

 When pulsating do it simultaneously and compare.

Brachial other side sang elbow.Ulnar tadlong sang pinky, radial tadlong sang
thumb.

40. Inspect palms of hands and palpate for temperature 210

Du something kaptan kag du icompare ang palms

41. Check for capillary refill 210

42. Test ROM of wrist 210

ROM: Flexion, extension, and hyperextension. Radial and ulnar flexion.

43. Test rapid alternating movements of hands 210

ANG GINMEMORIZE NGA 44-68

ASSESSMENT: LEGS, FEET AND TOES

I am now going to assess the Legs, feet, and toes

Pa batangon ang patient habang garecite tas ifold ang habol dangat sa tuhod sang
patient.

69. Inspect the lower extremities for over-all skin coloration, texture, moisture, 210
masses, lesions and varicosities. Note hair distribution

70. Observe muscles of the legs and feet 210

71. Palpate for pulses (femoral, popliteal, posterior tibial and dorsalis pedis) 210

Femoral- lapit sa sakang

Popliteal- under sang knees

Posterior Tibial- inner ankle

dorsalis pedis- ibabaw ka tiil

72. Palpate for edema, skin temperature, muscle size and tone of legs and feet 210

Palpate inner ankle using thumb

73. Palpate joint of hips, knees and ankles 210

74. Test ROM of hips, knees and ankles 210

ROM of hips:Abduction and adduction, flexion and extension.

ROM of knee:flexion and extensi.

ROM of ankle: plantar flexion and dorsi flexion

75. assess for capillary refill 210

I am now done with your head to toe assessment. Thank you for your cooperation.

I will now wash hands