I.

Head-to-Toe Assessment

General Survey
October 8, 2022
2:00pm
The patient is lying on bed, wearing white shirt He is alert and
conscious, 5’7” in height, 73kg, with vital signs of: T: 36.1°C, RR- 19
breaths per min, PR- 70 bpm, and BP- 110/70mmHg O2sat: 96%
AREAS METHODS FINDINGS INTERPRETATIO
N
1.HEAD Hair, scalp, Inspection  Shiny black  Normal
face hair
Palpation  No bumps  Normal

Eyes and Inspection  Eyes are  Normal

Vision symmetrical

 Pupils  Normal
constrict
when
diverted to
light and
dilates when
he gazes afar  Normal

 Conjunctiva is
clear and free
from lesions
Ears and Inspection  Ears are at  Normal
hearing the same size
and shape

 Normal
 Ears are
clean.
 Normal
 Patient can
 hear normally
when spoken
softly

Nose Inspection  No swelling of  Normal

the mucus
membrane

Mouth and Inspection  Tongue is  Normal

esopharynx
pink and is
free of
swelling and
lesions
 Normal
 Lips are
smooth and
moist without
lesions or
swelling.
2. NECK Muscles Inspection  Patient is able  Normal
to freely move
his neck.
Lymph nodes Palpation  Not palpable  Normal

3. UPPER Skin and Inspection

 Skin brown in  Normal
EXTREMITIE nails
S color
 Nails are  Normal
short and
clean
 Normal
 Good skin
Palpation turgor  Normal
 1-2 seconds
capillary refill
Muscle Inspection  Patient is able  Normal
to freely move
strength and
his arms
 tone

Joint ROM Inspection  Able to move  Normal

arms through
active ROM

 Normal
 Able to
extend arms
in front or
push them
out to the
side.

Brachial and Palpation  Palpable  Normal

brachial and
Radial pulse
radial pulse
Sensation Inspection  The patient  Normal

Was able to
react on pain
and can
differentiate
hot and cold

4. CHEST Skin Inspection  (-) lesions  Normal

AND BACK Palpation  No bumps
 No reports of
pain during
the inhalation
and
exhalation.
Lungs Auscultation  Absence of  Normal
adventitious
sounds upon
auscultation

Heart Auscultation  (-) murmur  Normal

  There were  Normal
no visible
pulsations on
the aortic and
pulmonic
areas
Spinal Inspection  (-)  Normal
deformities
column Palpation
5. ABDOMEN Skin Inspection  Abdomen is  Normal
Palpation flat, not
distended.
 No palpable
mass

Bowel sound Auscultation  Decreased  Constipation

due to
bowel sound
medication
(Morphine)
and reduce
mobility
Palpation  A palpable
 due to the
abdominal length of time
mass in the of the stool
stays in the
left lower colon that
abdominal results in
bloating
quadrant
6. LOWER Skin and toe Inspection  Nails are  Normal
EXTREMITIE nails Palpation short and
S clean
 Normal
 2 sec capillary
refill
 Normal
 Pinkish nail
beds
Gait and Inspection  Can walk and  Normal
balance sit on his own
Joint ROM Inspection  Can move his  Normal
legs

Popliteal, Palpation  Normal  Normal

popliteal,
posterior
posterior
tubial, tubial,
dorsalis pedis
Dorsalis
pulses
pedis pulses