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2. HEAD TO TOE
EXAMINATION

3. GENERAL SURVEY
Appearance and behavior
Gender and race
Age
Signs of distress
Body type (thin, muscular, obese or excessively
thin)
Posture (standing posture ,slumped ,erect or bent
posture and stooped posture)

4.  Gait
 Body movements
 Hygiene and grooming
 Dress
 Body odor
 Affect and mood
 Speech
 Client abuse
 Substance abuse

5. Vital signs
Temperature
Pulse
Respiration
Blood pressure

6. TEMPRATURE
Temperature:
Oral
Rectal
 Axillary
Tympanic membrane
Temporal artery
Thermometer
Normal : 98.6 F
Hyperthermia
Hypothermia

7. PULSE
Radial
Brachial
Carotid
Femoral
Popliteal
Dorsalis pedis
Posterior tibial BPM

8. Tachycardia (>100)
Bradycardia (<60)

9. RESIRATION
INHALATION
EXHALATION
RESPIRATION

10. Unit : Breathes Per Minute

11. BLOOD PRESSURE (mm hg)
• Systolic pressure
• Diastolic pressure

13. HEIGHT AND WEIGHT

14. Guidelines
Height
Client should remove the shoe and stand erect with
heels together, and the heels ,buttocks and back of the
head against the measuring stick ; eye should be looking
straight ahead.
The nurse raises the L-shaped sliding arm on the weight
scale until it rests on top of the client’s head ,or places a
small flat object such as a ruler or book on the client’s
head . The edge of the flat object should about the
measuring guide.

15.  Weight ;
 Weight usually measured when a client is admitted to
health agency and often regularly
 Use the same scale each time and at same time each day
(accuracy)
 Make sure the client has on a similar kind of clothing
and no footwear.
 Procedure : the client stands on a platform ,and the
weight is read from a digital display panel or a balancing
arm.
 Client who cannot stand are weighted on chair or bed
scales .

16. Chair Bed scale

17. MEASURMENT
HEIGHT ; METER
WEIGHT ; KILOGRAM

18. THE INTEGUMENT
Skin
Hair
Nail
Scalp

19. SKIN
Techniques
•Inspection
• Palpation
•Olfaction
Equipments
•Millimeter ruler
•Clean gloves
•Magnifying glass

20. color
Normal Deviation from normal
 Varies from light to
deep brown from
ruddy pink to light
pink; from yellow
overtones to olive.
 Pallor
 Cyanosis
 Jaundice
 Erythema

21. Jaundice Pallor
Cyanosis Erythema

22. Uniformity of skin color
Normal Deviation from normal
 Generally uniform
except in areas exposed
to the sun
 Lighter pigmentation
(palms , lips, nail beds)
in dark skinned people
 Hyper pigmentation
 hypo pigmentation

23. Uniformity of skin color
Vitiligo Albinism

24. Edema
Normal Deviation from normal
No edema

25. Pitting edema
Grades of pitting edema
0021 Grade 0 : (none)
 Grade +1 :( trace , 2 mm) Disappear rapidly
 Grade +2 ( moderate , 4 mm) 10-15 sec
 Grade +3 (deep, 6 mm) ≥ 1min
 Grade +4 (very deep, 8 mm) 2-5min

26. Skin lesions
Normal Deviation from normal
 Freckles ,some birth
marks ,some flat
and raised nevi; no
abrasions or other
lesions
 Various
interruptions in
skin integrity;
irregular
,multicolored or
raised nevi.

27. Primary skin lesions

28. Primary skin lesions

29. Primary skin lesions

30. Skin lesions

31. Skin moisture
Normal Deviation from normal
 Moisture in the skin
folds and the axillae.
(varies with
environmental
temperature and
humidity ,body
temperature and
activity)
 Excessive moisture
(hyperthermia)
 Excessive dryness
(dehydration )

32. Skin temperature
Normal Deviation from normal
 Uniform within normal
range.
 Generalized hyperthermia
(fever)
 Generalized hypothermia
(shock)
 Localized hyperthermia
(infection)
 Localized hypothermia
(arteriosclerosis)

33. Skin turgor (elasticity)
Normal Deviation from normal
 When pinched ,skin
springs back to
previous state; may be
slower in elders.
 Skin stays pinched or
tented or moves back
slowly (dehydration)

34. Skin turgor (elasticity)

35. HAIR
Technique
Inspection
Equipment
Clean gloves

36. CHARACTERISTICS NORMAL
DEVIATION FROM
NORMAL
Evenness
Evenly distributed hair Patches of hair loss
(Eg: alopecia)
Thickness or
thinness
Thick hair Very thin hair
( Eg: hypothyroidism)
Texture or oiliness
Silky , resilient hair Brittle hair
Excessively oily or dry
hair (hypothyroidism)
Infection or
infestations
No infection or
infestation
Flaking, sores, lice, nits
(louse eggs), and
ringworm
Amount of
body hair
Variable Hirsutism (abnormal
hairiness)

37. NAILS
Technique
Inspection

38. CHRACTERISTICS NORMAL
DEVIATION FROM
NORMAL
Finger nail shape Convex curvature; angle
of nail plate about 160
degree
Spoon nail
Clubbing (180 degree or
greater)
Fingernail and toe nail
texture
Smooth texture Excessive thickness or
thinness or presence of
grooves or furrows;
(Eg Beau’s line)
Finger nail and toe nail
bed color
Highly vascular and pink Bluish or purplish tint
(cyanosis)
Pallor
Tissues surrounding
nails
Intact epidermis Hangnails ; paronychia
(inflammation)
Blanch test Prompt return of pink or
usual color (<4sec)
Delayed return

39. Capillary nail refill test,
The nail blanch
test, also called the
capillary nail refill
test, is performed
on the nail beds as
an indicator of
tissue perfusion (the
amount of blood
flow to tissue) and
dehydration.

40. Spoon nail Clubbing Cyanosis
Beau’s line Paronychia

41. “Lets have brake”