Head-To-Toe Assessment


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

  1. Define physical assessment
  2. Describe the four techniques used in physical assessment
  3. Know how to do a head to toe assessment
Physical assessment
  • 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.
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.
  • 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.
General 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.

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

Vital signs
  • 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.
Skull, Scalp & Hair
  • 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.