Head-To-Toe Assessment

Objectives

By the end of the topic students should be able to:

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

It’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.

Principles of inspection

Availability of adequate light
Position and expose body part to view all surfaces
Inspect 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

It involves use of hands to touch body parts for data collection.
The nurse 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.

Principles of palpation

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

It 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.

It 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.

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.
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.

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.

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

Assessment 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.

Observe the size, shape and contour of the skull.
Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so. (wear gloves if necessary)
Observe and feel the hair condition.