PHYSICAL EXAMINATION

HEAD TO TOE ASSESSMENT

• A comprehensive head-to-toe assessment while coming in contact with the client & when it is needed to determine changes in hemodynamic status of the client.
• The head-to-toe assessment involves 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 specific assessment of the affected body system.

Preliminary Steps

• Perform hand hygiene.
• Check room for contact precautions.
• Introduce to the client.
• Confirm patient ID.
• Explain process to patient.
• Perform assessment in an organized & Systematic way.
• Use appropriate listening and questioning skills.
• Ensure patient’s privacy and dignity.
• Assess ABCCS (airway, breathing, circulation, consciousness, safety)/suction/oxygen.
• Apply principles of asepsis and safety.

Assessment Techniques

General Appearance

• Monitor the consciousness affect (Mood), behavior & Anxiety
• Assess the hygienic condition of Client
• Monitor the client’s posture
• Assess gait & mobility
• Monitor Speech Pattern & Articulation

SKIN HAIRS, NAILS

• Inspect the skin for color , Appearance & dryness
• Inspect for lesions, rashes & Bruises on the Skin
• Inspect for redness on the skin especially in the pressure points like heel, ankles, elbows, buttocks, hips etc.
• Palpate the skin for turgor moisture & Temperature
• Inspect the Skin for local & Generalized Edema
• Assess the Scalp for lesions, excoriations, Scratches, presence of dandruff, Lice & Nits
• Assess the hair for color, Texture & thickness
• Assess the nails for color, consistency & Capillary Refill

Head:

• Assess the Shape, size of Head
• Assess the size & shape of the fontanels in Infants
• Inspect the Symmetry of the Face
• Palpate for pain, Tenderness, Injury or Facial Puffiness
• Palpate for the Temporal & Frontal Pulses

Eyes:

• Inspect the eyes for the presence of eyebrows and eye lashes
• Inspect for discharges & color of the eye ball & Sclera
• Inspect the lens whether transparent or opaque
• Palpate the eye for tenderness
• Pupillary reaction to light
• Visual acuity using snellan’s chart

Ear:

• Inspect the ear for Shape, size, symmetry
• Inspect for cerumen (Ear wax) impaction
• Use of hearing aids or cochlear Implants
• Inspect for any drainage or bleeding peri-auricular ecchymosis  from the ears
• Assess hearing acuity using weber’s & Rinne’s Test
• Palpate the ears for any pain or Tenderness

Nose:

• Inspect the shape, size, symmetry of the Nose,
• Inspect for flaring of nares to identify respiratory conditions
• Assess the nasal cavity for septal deviation, discharges (Rhinorrhoea), nasal congestion & bleeding
• Palpate the Sinuses for pain & Tenderness
• Inspect the Sense of Smell by asking the client to tell the smell of powder with the eyes closed.

Mouth:

• Inspect the shape, size and symmetry, angular deviation of the mouth
• Teeth: Inspect the color, cleanliness, presence of dentures, no. of tooth present, cleanliness of mouth, any halitosis present, any infections like dental caries stomatitis, periodontitis & peri tonsillar abscess.
• Tongue: Inspect the color of the tongue, movement, Infections like Glossitis & sense of taste by placing sugar or salt in the tongue and tell the taste with the eyes closed
• Lips: Inspect for color, Dryness, cracked Lips, lesions &Infections like cheilosis suggestive of Vitamin B2 deficiency

Neck and Throat:

• Neck: Inspect the shape & size of the neck & use of Sterno-cleido muscles for Breathing
• Palpate for tracheal shift, presence/ absence  of Jugular Venous Distension, thyroid gland enlarged or normal & the  presence of carotid pulses
• Throat: Using Torchlight/ Laryngoscope Inspect the color & presence of Tonsils, ability to swallow & speak

Chest:

• Respiratory: Inspect the shape, size & symmetry, antero-posterior & lateral (1:2) diameter of the chest, chest wall movement for bilateral air entry clear/not clear , Thoracic Retractions , use of Accessory muscles for breathing, shortness of Breath & check the Respiratory Rate
• Percuss the Thoracic wall for Resonance, Hyper Resonance & dull or flat Sounds
• Auscultate for the respiratory sounds.
• CVS (Heart): Inspect for visible heaves, shape & Size of the Chest
• Palpate for masses & Tenderness & apical Pulses
• Auscultate for S1 & S2 sounds heard or any abnormal sounds heard.

Abdomen

• Inspect the abdomen for shape ( Scaphoid, round, oval or pendulous), size and symmetry, color, texture, distension & fullness
• Auscultate the abdomen & note for the bowel Sounds
• Palpate for pain, tenderness, masses, nodes, organomegaly in each quadrant of the abdomen, and presence of any fluid thrill.
• Percuss for the dull, flat & tympany sounds.

Extremities:

• Inspect the Shape/ deformity, size, Symmetry, color of both Upper & Lower Inspect for the presence & type of edema & Inspect the pressure points for bruises & sores. Inspect the skin for dryness & Integrity
• Determine the range of motion & exercises are possible/not possible in both the extremities
• Palpate brachial, radial, ulnar pulsation of upper extremities & femoral, popliteal, tibial, pedal pulsation of lower extremities. Palpate for the warmth & Sensation of Extremities by placing warm or cold water. Palpate for hand grip & strength of the muscles by asking them to move the extremities against Resistance
• Inspect for the abnormality like polydactyl (Extra Fingers), syndactyly (fused Fingers) or amputated limbs

Genitalia & Rectum

• Genitalia : Inspect the Genitalia for any discharges, painful ulcers, redness, presence of catheters , sutures, cleanliness, smell, any excoriations
• Palpate for Prostatic enlargement & scrotum and penis for pain discharges & Excoriations in males
• Rectum: Inspect for any hemorrhoids or fistula present
• Palpate for the presence of Nodes, Masses Tumors & Fecal Impaction

Back and Spine

• Inspect the Spine for any deformities like Kyphosis, Scoliosis, Kyphoscoliosis & Lordosis. Inspect for any pressure Sores, Bruising in the Skin
• Inspect for the Movement, flexion, Posture & Gait

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