IT IS HELPFULL FOR PHYSICAL EXAMINATION HEAD TO TOE CREATED BY- MR. SANDEEP YADAV MSC. NURSING 1ST YEAR FROM KGMU LUCKNOW UP.

1. Presented By:
Sandeep Yadav
M.Sc. (N) 1st year
KGMU lucknow

2. OBJECTIVES
 Define the physical examination
 Explain the purposes
 Discuss the indication
 Enlist the articles
 Discuss the pre-procedural steps
 Explain the procedure and demonstrate
 Dicuss the post procedural steps
 Discuss about the nursing responsibilities.

3. INTRODUCTION
 A comprehensive head-to-toe assessment is
done on patient admission or in community
centre, and when it is determined to be
necessary by the patient’s health status. 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.

4. DEFINITION
 It is the systematic collection of objective
information that is directly observed or is
elicited through examination techniques.

5. PURPOSES
 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.

6. INDICATIONS
 check for possible diseases so they can be
treated early
 identify any issues that may become medical
concerns in the future
 update necessary immunizations
 ensure that you are maintaining a healthy diet
and exercise routine.

7. ARTICLES

8. GLOVES

9. SPHYGMOMANOMETER

10. STETHOSCOPE

11. FETOSCOPE

12. TONGUE DEPRESSOR

13. FLASH LIGHT

14. TAPE MEASURE

15. WEIGHING MACHINE

16. LARYNGOSCOPE

17. OPTHALMOSCOPE

18. OTOSCOPE

19. TUNNING FORK

20. NASAL SPECULUM

21. PERCUSSION HAMMER

22. VAGINAL SPECULUM

23. PRCOTOSCOPE

24. WATCH

25. SCALE WITH HEIGHT
MEASURE

26. SNELLEN CHART

27. PULSE OXYMETER

28. COMMUNITY BAG

29. COTTON BALL

30. COTTON APPLICATOR

31. LUBRICANT

32. DISPOSABLE NEEDLE &
SYRINGE

33. GAUZE, BANDAGES

34. PAPER TISSUE

35. SPECIMEN CONTAINER

36. PRE-PROCEDURAL
STEPS
 Prepare yourself
 Prepare environment
 Prepare the client
 Psychological preparation of client like—Remain calm
,Explain each procedures, Allow client to feel free to
ask questions and mention any discomfort, give
comfortable position like—sitting, prone, supine, knee
chest, lithotomy etc.

37.  Hand hygiene
 Introduce yourself to patient.
 Confirm patient ID using two patient identifiers (e.g.,
name and date of birth).
 Use appropriate listening and questioning skills.
 Listen and attend to patient cues.
 Ensure patient’s privacy and dignity.
 Make patient comfortable.
 Ensure working condition of equipment.
 Check vital signs.

38. PROCEDURE STEPS

39. IDENTIFICATION
INFORMATION
 Full name ----
 Age ----
 Gender ----
 Father name ----
 Mother name -----
 Education status -----
 Caste & religion ----
 Address ----
 Occupation -----
 Health problem ----

40. EXAMINATION
HEAD TO TOE

41. GENERALAPPEARANCE:-
 Nourished – well nourished/ undernourished
 Body build—thin/obese
 Activity—active/dull
 Look—anxious/worried/happy

42. HEAD & FACE:-
 Shape of skull—round in shape/oval/flat/any
injury/any suture
 Scalp—cleanliness/hair condition/dandruff /
pediculi /infection like ringworm
 Shape & colour of hairs or any other.
 Face—colour like pale /flushed / puffiness
/fatigue /pain /fear/anxiety/enlargement of
parotid gland etc.

43. MOUTH
 Lips—normal (pink or moist) /abnormal (swelling
/crusts/cyanosis/redness/angular stomatitis)
 Odour of mouth—foul smelling or other type
smelling
 Mucus membrane & Gums—ulceration and
bleeding/swelling /pus formation /gingivitis
/tongue pale or dry/any lesions/ sores/ furrows/
tongue tie/ coated
 Throat & pharynx—enlarged tonsils/redness/pus
 Teeth—normal/plague/tarter/dental
caries/pyorrhea/any other

44. TONGUE FURROWS-TOUNGE TIE

46. TONSILS --- TARTER TEETH

47. PYORRHEA --- GINGIVITIS

48. EYES
 Eye brows—normal /absent
 Eyelashes—infection/sty
 Eyelids--oedema/ lesion/ ectropion (eversion)/ entropion (inversion)
 Conjunctiva—pale/red/purulent
 Eye ball—sunken/protruded
 Sclera—jaundiced
 Fundus—congestion/hemorrhagic spots
 Eye muscles—strabismus(squint)
 Lens—opaque/transparent
 Cornea—normal/abnormal
 Pupils –dialted/constricted/reaction to light
 Vision—normal/ myopia/ hypermetropia/ any other/lacrimal
obstruction.

50. INVERSION EVERSION

54. NOSE
 External nares—crusts or discharge
 Nostrils—inflammation of the mucus
membrane/septam deviation.

56. NECK
 Lymph nodes—enlarged and palpable
 Thyroid gland—enlarged
 Range of motion—flexion/extention and
rotation

57. LYMPH NODES

59. EAR
 Discharge /cerumen obstruction/ perforation/
fungal infection/ any other specify
 Hearing—normal /abnormal

61. PERFORATION OF EAR

62. SKIN
 Colour—pallor/jaundice/cyanosis/flushing etc.
 Texture—dryness/flaking/wrinkling or
excessive moisture
 Temperature—warm/cold and clammy
 Lesions—macules/papules/vesicles/wound
pastule/any other abnormally specify

63. FLUSHING SKIN

64. FLAKING SKIN

66. NAILS
 Normal/clubbing/fungal inection/brittles
nails/soft/whitish/any others specify

68. BRITTLE NAILS – FUNGAL NAILS

69. EXTREMITIES
 Movements of joints/tremors/clubbing of
fingers/ankle oedema/varicose vein/reflexes

70. ANKLE OEDEMA—VERICOSE VEIN

71. ABDOMEN
 Skin rashes /scar /hernia /ascitis/ distension
/palpable spleen/tenderness/presence of
gas/fluid or masses present

72. POSTURE
 Body curve—lardosis/kyphosis/scoliosis
 Back—spina bifida/curves
 Gait—normal/abnormal

75. CARDIOPULMONARY
SYSTEM
 Cough/wheezing/crackles/tachycardia/bradycar
dia/palpitation/cardiac murmur/any other
specify

76. GASTROINTESTINAL
SYSTEM
 Normal/diarrhea/constipation/ulcer/nausea/vom
iting/acidity/spasm/abdominal distention/bowel
movements/any other

77. FUNDAMENTAL SIGNS
 Height
 Weight
 Temperature
 Pulse/heart rate(per minute)
 Respiration(beats per minute)
 Blood pressure(mm/hg)

78. ACTIVITIES OF DAILY
LIVING
PERSONAL HYGIENE HABITs
 Bathing pattern—daily/alternate/no fix/less
frequent
 Water preference for bathing—hot/cold/lukewarm
 Oral care—one time in a day/morning and
evening/more frequent
 Oral care method—uses finger
cleaning/toothbrush/neem stick
 Oral care content—use paste/powder/charcoal

79. SLEEPING PATTERN
 Type of sleeping—sound /disturbed
 No. of sleeping hours—at night/during day

80. ILL HABITS
 Smoking—yes/no if yes-no. of cigarette/Biri
per day
 Drinking—yes/no, if yes,
habitual/social/occasional/addicted/
 Chews(tobacco)—yes/no,if yes, specify brand
 Any other habit affecting health

81. NUTRITIONAL HABITS
 Like/dislike of food
 Food pattern—veg/nonveg/eggtarian
 Frequency in a day
 Appetite—good/moderate/poor
 Any other important information about
nutrition

82. ELIMINATION
ACTIVITIES
 Bowel pattern—no. of bowel movement/day
 Any other difficulty (as constipation,diarrhea
ets)
 Urinary pattern—friquency of micturition
times/day or times/night any other difficulty (as
nocturia,dysuria,incontinence etc)


83. REPRODUCTION (FOR
FEMALE)
 Menstruation—
regular/irregular/dysmenorrhoea
 If amenorrhea LMP
 If abnormal, specify sexual
disorder/dysfunction

84. FOR MALE
•Lesions, pain, prostate problems, infections,
discharge, testicular pain
•Pubic region: Assess for normal hair distribution
and presence of body lice and see any tenderness,
masses present in pubic region.
•Penis: identified if patient circumcised or
uncircumcised. If uncircumcised , ask the pt to
retract the foreskin himself

85. Contd..
•Palpate the testes for tenderness or masses
•testes are normally equal in size, however when
the male is standing, it is normal for one testicle
to be lower in the scrotal sac than the other.
Observe the penis and testes for any lesions or
rashes.

86. LABORATORY
INVESTIGATION/CLINICAL
DIAGNOSTIC REPORT
 Description of the investigation
TREATMENT REPORT
 Description of the treatment

87. PERSON HEALTH
CONDITION(ON THE BASIS
OF PHYSICAL
EXAMINATION,DIAGNOSIS
AND TREATMENGT
HISTORY)

88. POST PROCEDURAL
STEPS
 Record findings and assessment performa
 Make patient comfortable
 Replace all articles back in utility room after
cleaning and disinfection
 Give relevant health education according to
history and physical assessment.

89. NURSING
RESPONSIBILITIES
 Provide the psychological support to the patient
 Provide comfortable position
 Identify the patient for the procedure
 Take care of all articles before examination
check all articles are working correctly or not
 Provide comfortable environment to the client
like- light, temperature etc.
 Maintain privacy for the patient
 Provide health education to the patient

90. CONCLUSION
 Physical Examination is important for everyone.
It is an assessment in which we judge the
physical quality of the person. It is an evaluation
in which we detect a disease in the person who
look and feel well by taking a physical exam.
The technique of assessment involves
inspection, palpation, percussion and
auscultation.

91. Evaluation/recapitalization
 Define the physical examination
 Explain the purposes
 Discuss the indications
 Enlist the articles
 Discuss the pre-procedural steps
 Explain the procedure
 Discuss the post procedural steps
 Discuss about nursing responsibilities

92. Bibliography
 Ghai Sandhya, Textbook of Clinical Nursing
Procedures, CBS Publishers & Distributors
Pvt. Ltd., Page No. 204 to 212