nb

1. Head to toe
Framework
(Physical fitness)

2. DISCOVER YOUR
PURPOSE AND YOU
DISCOVER YOUR TRUE
POTENTIAL
-ANONYMOUS

3. Purpose of
physical
assessment
* Screening of general well being. The
finding will serve as baseline information for
future assessment.
• Validation of the complaints that brought
the patient to seek health care.
• Initial comprehensive assessment
• Focus/problem related assessment
• Emergency assessment
• On going/partial assessment

4. Purposes of
physical
assessment
◦ Monitoring of current health problems.
◦ Formulation of diagnoses and treatments.
Things to Consider
F always consider client’s time and energy.
F do the assessment systematically and
efficiently.
F may assess only a specific body area based
on client’s complaints, nurses observation of
problems & nursing interventions provided.

5. Head to toe
framework
◦1. General survey
◦2. vital signs

6. SHEEN
T
◦ Skin (scalp, face)
◦ Head and Neck
◦ Eyes and Vision
◦ Ears and Hearing
◦ Nose and Sinuses
◦ Throat and Mouth

7. Neck
◦ Muscles
◦ Lymph nodes
◦ Trachea
◦ Thyroid gland
◦ Carotid arteries
◦ Neck veins

8. Upper
extremities
◦ Skin and Nails
◦ Muscles strength and tones
◦ Joint range of motion
◦ Brachial and radial pulse
◦ Bicep tendons reflexes
◦ Tendon reflexes
◦ Sensation

9. Chest and
Back
◦ Skin
◦ Chest shape and size
◦ Lungs
◦ Heart
◦ Spinal column
◦ Breast and axillae

10. Abdomen
◦ Skin
◦ Abdominal sound
◦ Specific organs
◦ Femoral pulse

11. Genitals
◦ Testicles
◦ Vagina
◦ Urethra
◦ Anus and rectum

12. Lower
extremities
◦ Skin and toenails
◦ Gait and balance
◦ Joint range of motion
◦ Popliteal, posterior tibial and pedal pulse
◦ Tendon and plantar reflex

13. TECHNIQUES OF
PHYSICAL ASSESSMENT

14. TOOLS OF PHYSICAL
ASSESSMENT

15. Inspection
◦ Always begin with inspection
◦ Inspection is the most frequently used
assessment technique.
◦ Sense of sight but also your senses of
hearing and smell to inspect your patient
critically.
◦ Do not rush the process; take your time and
really look at your patient.

16. Inspection
◦ Be sure you have adequate lightning.
◦ Make sure the room in a comfortable
temperature
◦ Completely expose the body part you are
inspecting while draping the rest of the
client as appropriate.
◦ Be systematic, working from head to toe and
noting key landmarks and normal findings
◦ Compare the appearance of symmetric body
parts or both sides of any individual body
part

17. TYPES OF INSPECTION

18. Direct
inspections
◦ Involves directly looking at your patient.

19. Indirect
inspections
◦ Involves using equipment to enhance
visualization
◦ E.g oto/opthalmoscope allows better
visualization of the ears and eyes