This document provides guidance on performing a head-to-toe assessment. It outlines how to check the patient's vital signs, mental status, skin, heart, lungs, abdomen and extremities. Proper techniques are described for listening to breath and bowel sounds. The document also reviews how to evaluate pulse, edema, neck veins, reflexes and other physical exam findings. The goal is to demonstrate the full process for a comprehensive patient examination.

1. Christi Scott, RNChristi Scott, RN

2.  By theend of thispresentation, studentswill be
ableto:
 Demonstratewhereto listen for an apical
pulse..
 Demonstrateproper techniquefor listening to
breath sounds.
 Demonstratehow to assessfor pitting edema.
 List thethreewaysto assessthepatient’s
mental statusand orientation.
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3.  Knock and introduceyourself.
 Wash your handsand don glovesprior to touching
thepatient.
 Establish rapport by using eyecontact.
 Sit at thelevel of thepatient if possible.
 Explain all proceduresto thepatient prior to
performing them.
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4. Vital Signs
PulseRate, Strength, Regularity
Temperature________ Oral, Rectal, Tympanic
Respiration_______________
B / P_________
Pain Assessment _________________
Oxygen saturation ________________
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5. Assessing ForPain (PQRST method)
P– Provokes, palliativemeasure
Q – Quality (describe)
R – Region, radiate?
S– Severity, on ascaleof 0 - 10
T – timing, when did it start?How long doesit last?
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6. Orientation – time, person, place, reason
Can you tell me your name?
_______________________
Can you tell me whereyou are?
____________________
Do you know what today'sdateis?
__________________
Pupil Check
( PERRLA ) Pupils, Equal, Round, React to light,
Accommodate
Sluggish ( ) No Change( ) Brisk ( ) Normal ( )
Accommodation Yes( ) No ( )
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7. Neck Veins
Patient at 45 degreeangle( )
Neck VeinsFlat ( ) Distended ( )
 Neck veinsshould bechecked by having thepatientNeck veinsshould bechecked by having thepatient
sit at a45 degreeangle. In thisposition, thejugularsit at a45 degreeangle. In thisposition, thejugular
veinsshould beflat.veinsshould beflat.
 Distended neck veinsat 45 degreesarean indicator ofDistended neck veinsat 45 degreesarean indicator of
over hydration or fluid overload.over hydration or fluid overload.
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8. Edema, or fluid in thetissuestendsto
go to dependent areasof thebody.
Thismay bethehands, feet or
sacrum.
To check for edemapush your finger
down on thefoot over thedistal end
of thetibiaand observefor
indentation or pitting.

9. 1+ slight pitting, no visible distortion, disappears
rapidly
2+ somewhat deeper pit than 1+, no readily
detectable distortion, disappears in 10-15 sec.
3+ pit noticeably deep, may last more than a
minute; the dependent extremity looks fuller
and swollen.
4+ pit very deep, lasts 2-5 min; dependent
extremity is grossly distorted.

10. Heart Tones
Apical Pulsewith Stethoscope
Rate?_____________
Rhythm ?___________
Clarity of Sounds?_________ Abnormal ?
Explain ! ____________________________
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11. 11
Ape(Apical and
Pulmonic)
To(Tricuspid)
Men(Mitral)

12. Heart tonesarechecked by listening to
theapical pulsefor atotal of one
minute.
Thispulseisauscultated with thebell
of thestethoscope.
Check theapical pulsefor rate, rhythm,
and clarity of thesoundsof theS1
and S2 otherwiseknown as"lub
and dub".
Any abnormalitiesshould bereported.

13. Bilateral Pulse Checks
 ( Radial Pulses ) - Rate, Strength, Regularity
Right_____________ Left______________
 ( Pedal Pulses – DP/PT) - Top of Foot
Right Foot __________ Left Foot ____________
 ( Capillary Refill ) - On fingersor toes3 secondsor less
Right Fingers( ) sec. Left Fingers( ) sec.
Right Toes( ) sec. Left Toes( ) sec.
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14. DorsalisPedis
(To locatepulsedraw astraight line
back from thepatientsgreat toeto the
middleof thedorsum of thefoot)

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17. Breath Sounds
 Assessanterior and posterior and from sideto side,
left to right lobeusing thediaphragm of the
stethoscope.
 Havepatient takedeep breaths, do not move
stethoscopeto rapidly to avoid hyperventilation.
 Havethepatient takedeep breathsin and out of their
mouth asnosebreathing can createair turbulence
that may alter thesounds.
 Breath soundsshould beclear bilaterally with good
air flow.
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18. Normal breath sounds
Bronchial sounds - Pitch: High. Intensity: Loud,
predominantly on expiration. Normal findings: A
sound likeair blown through ahollow tube
Bronchovesicularsounds - Pitch: Moderate. Intensity:
Moderate. Normal findings: A blowing sound heard
over airwayson either sideof sternum, at angleof
Louis, and between scapulae
Vesicularsounds - Pitch: High on inspiration, low on
expiration. Intensity: Loud on inspiration, soft to absent
on expiration. Normal findings: Quiet, rustling sounds,
heard over periphery

19. ADVENTITIOUSSOUNDS
 FineCrackles(Rales)
Over lung fieldsand airways; heard in lung basesfirst with
pulmonary edema
Moreaudibleduring inspiration
Cause: Moisture, especially in small airwaysand alveoli
SoundslikeRiceCrispiesCereal.
 Rhonchi / CoarseCrackles
Heard larger airways.
Morepronounced during expiration
Caused bronchospasm or secretions
Soundslikerattling, usually louder and lower-pitched than
finecrackles. Clearswith coughing.

20.  Wheezes
Heard over lung fieldsand airways
Inspiration or expiration
Caused bronchospasm
Soundslikeahigh pitched whistle
 Pleural Friction Rub
Heard at front and sideof thelung fields
Inspiration
Causeby theinflamed parietal and visceral pleural surfaces
rubbing together.
Soundslikegrating or squeaking.

21. Bowel Sounds
 Assessall 4 quadrants, do not touch stomach before
auscultation, asit may disrupt normal sounds. If
irregular,
 1 minuteassessment on each quadrant to accurately
record no bowel soundspresent.
 ( Stomach ) – Inspect and palpatefor condition
Soft ( ) Hard ( ) Distended ( ) Other
 RUQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )
 RLQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )
 LUQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )
 LLQ Active( ) Absent ( ) Hyperactive( ) Hypoactive( )
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22. Ask the patient about:
Urgency, burning, incontinenceand pain.
Assess:
Catheter, drainage, urineoutput.
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23. Skin
 Skin Turgor - 1 to 3 second return on thedorsum of the
hand.
 Skin Color - Check on insideof Lip or Conjunctiva
Lip ( ) Conjunctiva( )
Pink ( ) Pale( ) Jaundice( )
 Skin Temperature- Useback of hand to check
Hot ( ) Warm ( ) Cool ( )
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24. 0 No defection of muscular contraction
1 A barely detectable flicker or trace of contraction with
observation or palpation
2 Active movement of body part with eliminations of gravity
3 Active movement against gravity only and not against
resistance
4 Active movement against gravity and some resistance
5 Active movement against full resistance without evident
fatigue (normal muscle strength)