Poer point about head to toe examination which show steps and equipment used for assessment

1. Head to toe assessment
Done by :
- Nouf Nahari - Eman Arishi
- Ohood Al-Balawi - Fatma Alsawqaee
- Safa mashikhi - Ghamra alshiban
- Ahlam Ibrahim Al-Asmary - Sharifah Alsallami
Supervised by Dr. Maysa Mohd.

2. Introduction
Assessment is a key component of nursing
practice, required for planning and provision
of patient and family- centered care.
comprehensive head-to-toe assessment is
done on patient admission. The head-to-toe
assessment includes all the body systems, and
the findings will inform the health care
professional on the patient’s overall condition.

3. Purpose
• To understand the physical and mental well being of the patient.
• To detect diseases in early stages
• To determine the cause of disease
• To understand any changes in the condition of diseases, any
improvement or deterioration.

4. Definition
head-to-toe assessment is a
procedure carried on a patient’s bod
parts from the head throughout to
the toe. It should be done each time
you encounter a patient for the first
time each shift (or visit, for home
care, clinic or office nurses). An
accurate assessment requires an
organized and systematic approach
using the techniques of inspection,
palpation, percussion, and
auscultation

5. Steps of assessment
1- Inspection: is Visual examination of a person . This is done in an orderly
manner, focusing on one area of the body at a time
2- Palpation: Examination by touch . The nurses feels for texture, size,
consistency, and location of body parts
3- Auscultation: Examination by listening for sounds produced within the
body
4- Percussion: Examination of the body by tapping it with the fingers

6. Inspection
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.

7. Principals 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

8. Palpation
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.

9. 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

10. Percussion
• 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.

11. Auscultation
• 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.

12. EQUIPMENT REQURIED FOR HEAD-TO-TOE
EXAMINATION

13. Assessment procedure
• Vital signs :
• Temperature
• Pulse
• Respiration
• Blood pressure
 Height
 Weight
• General Appearance:
• Nourishment: well-nourished /
undernourished
• Body build: thin / obese
• Health: healthy / unhealthy
• Activity: Active / dull(tired)

14. • Skin Conditions
• Color: Pallor/jaundice/cyanosis/flushing. etc.
• Texture: dryness/wrinkling/excessive moisture
• Temperature: Warm/cold/clammy
• Lesions: papules/wounds, etc.
• Head and Face
• Shape of the skull and fontanel
• Skull circumference
• Scalp : Cleanliness/ condition of the hair
/dandruff/ infections like ringworm
• Face: Pale/ fatigue/ pain /fear / anxiety /
enlargement of parotid glands, etc.

15. • Eyes
• Eye brows: normal / absent
• Eye lashes: infection / sty
• Eye lids: Oedema / lesions
• Eye balls: Sunken / protruded
• Sclera: Jaundiced
• Pupils: Dilated/ constricted
reaction to light
• Lens: Opaque / transparent
• Eye muscles: Strabismus[squint]
• Vision: Normal / myopia
/hypermetropia.
Ophthalmoscope

16. • Ears
• External ear: discharge
• Tympanic membrane:
Perforations / lesions / bulging
• Hearing : Hearing acuity
• Nose
• External nares: Crusts /
discharges
• Nostrils : Inflammation of the
mucus membrane / septal
deviations
Otoscope
Nasal speculum

17. • Mouth and Pharynx
• Lips: Redness / swelling / cyanosis
• Odor of the mouth: foul smelling
• Teeth: Discoloration and dental
caries
• Mucus membrane & gums:
Ulceration & bleeding / swelling /
pus formation
• Tongue: pale / dry / lesions /
tongue tie / sords
• Throat and pharynx : Enlarged
tonsils / redness / pus
Laryngoscope Tongue depressor

18. • Neck
• Lymph nodes: enlarged / palpable
• Thyroid gland: enlarged
• Range of motion: Flexion /
extension / rotation
• Chest
• Thorax: shape / symmetry of
expansion / posture
• Breathe sounds: sigh / swish /
rustle / wheezing / rales / pleural
rub, etc.
• Heart : Size and location / cardiac
murmurs

19. • Abdomen
• Inspect abdomen for distension,
asymmetry
• 2. Auscultate bowel sounds
• 3. Palpate four quadrants for
pain and bladder/bowel
distension (light palpation only)
4. Check urine output for
frequency, colour, and odour.
• 5. Determine frequency and
type of bowel movements.

20. • Genital and Rectum
• Male
• Descent of the testes
• Presence of sexually transmitted diseases
• Hemorrhoids
• Enlargement of the prostate gland
• Female
• Vaginal discharges
• Presence of STD’s
• Hemorrhoids
• Pelvic masses
• Extremities
• Movement of joints / tremors / clumbing of fingers /
Ankle edema / reflexes, etc.
Protoscope

21. Nurse care plan
• The nursing should write every
diagnosis
• write beside every diagnosis
the appropriate planning
• Implementation
• Evaluation for every diagnosis

22. Evaluation
• Evaluation involves determining the effectiveness of the nursing care plan
in achieving the desired outcomes and goals. Nurses assess the patient's
response to the interventions and modify the plan as necessary. If the goals
are met, the care plan may be revised to focus on the patient's ongoing
health maintenance. If the goals are not achieved, the nurse reassesses the
situation, identifies any barriers or challenges, and makes appropriate
adjustments to the plan.

23. Documentation
• Accurate and thorough head-to-toe assessment documentation is essential. You
should record your findings in a clear, concise, and organized manner. This
includes noting vital signs, patient history, and the systematic assessment of
each body system.
• Your head-to-toe assessment nursing notes should be objective, focusing on
what was observed and avoiding personal opinions or assumptions.
Documenting any abnormalities, changes in condition, or concerns is important
for effective communication among the healthcare team.

24. References
1. Ruth F. Craven Constance J. Hirnle, Fundamentals of Nursing, Human
Health and Function, sixth edition(2009), Lippincott Williams &
Wilkins.
2. Potter. Perry, Fundamentals of Nursing, 7th edition(2009) Mosby
Elsevier.
3. Barbara F. Weller, Nurses Dictionary for nurses and health care