d.

Head-to-toe assessment

(1) Integumentary System

(a) Ask if patient has been exposed to harmful environmental materials or increased sun exposure, has recent skin changes, or is currently taking medications

(b) Normal skin color

1) Varies among races and individuals

2) Ranges from pinkish white to various shades of brown

3) Exposed areas may vary in color with unexposed areas

4) Healthy dark skin has a reddish undertone; buccal mucosa, tongue, lips, nails, normally appear pink

(c) Skin color assessment

1) Cyanosis - dusky bluish color

a) Inspect ears, lips, inside of mouth, hands, nailbeds

b) Caused by respiratory or cardiac diseases, or cold environment (decreased oxygenation)

2) Jaundice - yellowish color

a) Inspect skin, mucous membranes, sclera

b) Caused by liver disease (increased bilirubin)

3) Pallor - paleness

a) Inspect face, lips, conjunctival, mucous membranes

b) Caused by anemia (decreased hemoglobin) or inadequate blood circulation

4) Erythema - redness

a) Inspect facial area, localized areas

b) Caused by blushing, alcohol intake, fever, injury, infection

(d) Vascularity - bleeding or bruising

1) Ecchymosis - collection of blood in subcutaneous tissues causing purple discoloration

2) Petechiae - small hemorrhagic spots caused by capillary bleeding

NOTE: Note location, color, size of vascular findings.

(e) Lesions - note presence of wounds, scars, rash, etc.

(f) Note skin temperature and moisture - normally warm and dry

(g) Skin turgor - fullness or elasticity of skin

(h) Edema - excess fluid in tissues characterized by swelling with shiny skin

(i) Edema scale

0 = None +1 = Trace +2 = Moderate +3 = Deep +4 = Very deep

(2) HEENT - Head, eyes, ears, nose, throat (inspection and palpation)

(a) Head - size, shape, symmetry, tenderness

(b) Eyes

1) Symmetry, alignment and movement of eyes, eyelashes, eyebrows, eyelids, pupils

2) Visual acuity and peripheral vision

3) Pupils are normally black, equal in size, round, smooth

(c) Ears

1) Hearing; shape, size, symmetry of external ear

2) Palpate external ear for pain, edema, lesions

3) Ear canal should be smooth and pinkish - examine for wax, discharge, foreign bodies

(d) Nose/sinuses

(e) Throat - inspect lips, gums, teeth, tongue, hard and soft palates

1) Uvula normally centered and freely movable

2) Tonsils normally small, pink, symmetrical in size

(3) Nervous System / Neurological Assessment

(a) Mental Status

1) Orientation level - person, place, time

2) Observe patients' appearance, general behavior, response to questions, ability to speak clearly

3) Note memory recall - short and long term

(b) Pupillary reaction to light, accommodation, convergence

(c) Motor ability - note abnormal balance, gait, or coordination

(d) Sensory function - response to pain, light touch

(4) Thorax and lungs (respiratory)

(a) Inspection

1) Shape of chest

2) Breathing patterns

3) Rate of respirations

a) Bradypnea - Rate less than 12 respirations per minute

b) Tachypnea - Rate greater than 20 respirations per minute

c) Dyspnea - Breathlessness or difficult breathing

d) Orthopnea - Shortness of breath when lying down

e) Kussmaul - Faster and deeper respirations than normal without pauses

f) Cheyne-Stokes - Cyclic pattern which progresses from slow and shallow to fast and deep with a gradual return to slow and shallow respirations, followed by a period of apnea

(b) Palpation - detect areas of sensitivity, chest expansion during respiration

(c) Auscultation - auscultate anterior and posterior fields (upper, middle, and lower lobes)

1) Rales (crackles) - fizzing sound produced by moisture in airways

2) Rhonchi - Coarse, gurgling sound in bronchial tubes - low pitched - resulting from air flow across passages which are narrowed by fluids, tumors, swelling

3) Wheezes - Type of rhonchi - squeaky sound - high pitched

4) Cough - Note whether the cough is productive or non-productive and character of secretions

(5) Cardiovascular System

(a) Inspect the neck and epigastric areas for visible pulsations

(b) Palpate

1) Pulses

2) Edema

3) Capillary refill

a) Acceptable - < 3 seconds

b) Abnormal or sluggish - > 3 seconds

(c) Auscultate - Heart sounds

1) Rate - per minute

2) Rhythm - regular or irregular

(6) Gastrointestinal

NOTE: Be sure the patient has an empty bladder and that he/she is lying flat with knees slightly flexed.

(a) Flat

(b) Protuberant - (A part that is prominent beyond a surface).

3) Concave

4) Note local bulges/scars, note color of scars

NOTE: Inspect the general contour of abdomen

(b) Auscultate

NOTE: This is done before palpation because the latter may alter the character of bowel sounds.

a) Auscultate each of four quadrants in a clockwise systematic manner

b) Normal frequency ranges from 5-34 bowel sounds per minute, described as audible, hyperactive, hypoactive, or inaudible

NOTE: Character of bowel sounds (clicks and gurgles produced by movement of air and flatus in GI tract)

NOTE: Listen for 5 minutes in order to distinguish inaudible from audible bowel sounds.

(c) Palpate all four quadrants and note:

1) Muscular resistance

2) Tenderness

3) Enlargement of organs

4) Masses

NOTE: Appetite, usual elimination patterns, character of stool, recent changes, artificial orifices, and use of laxatives should be assessed during the interview.

(7) Genitourinary

(a) History of urinary elimination

1) Unusual patterns of elimination

2) Recent changes

3) Aids to elimination

4) Present or past voiding difficulties

(b) Inspection

1) Urine

a) Color

b) Clarity

c) Odor

2) Urethral orifice for signs of inflammation/discharge

3) Always inspect testis if patient presents with abdomen pain or urinary tract symptoms

(c) Palpate suprapubic areas and note

1) Tenderness

2) Distension

(8) Musculoskeletal

(a) Inspection and palpation

1) Gait

2) Muscles

a) Bilateral symmetry

b) Tenderness

c) Strength/tone

3) Joints

a) Note active/passive range of motion (ROM) - Joint movements include flexion, extension, hyperextension, abduction, adduction, pronation, supination.

b) Palpate joints and note - Pain, swelling, nodules, crepitation (grating sound heard on movement)

4) Bones

a) Note normal contour or prominences, symmetry

b) Document pain, enlargement, and changes in contour

Guidelines for Documentation of Physical Assessment a. Each body system is assessed for normal and abnormal findings, and documentation should occur in an organized manner

b. Data should be recorded legibly using correct grammar

c. Use only standard approved medical abbreviations

d. Subjective data should be recorded using patient's own words

e.Do not record data using nonspecific terms, i.e. adequate, good, normal, poor, large be specific

GENERAL APPEARANCE JG is a 48 yo white male, Ht. 511?, Wt. 190 lbs. admitted for chest pain; R/O MI. Well groomed, appears stated age, well nourished, alert & oriented x 4, no acute signs of distress. Wt. appropriate to ht.; erect posture, no obvious physical deformities. Understandable speech; intact memory; mood appropriate to situation. Smooth, even, wellbalanced gait, no involuntary movements. Sedentary lifestyle. Denies recent wt. changes; no appetite changes. Denies alcohol or illegal or prescription drugs; no food allergies. Complains of pain in right shoulder; pain rating 5/10. Dietary intake is adequate to protein and energy needs. No clinical signs of nutrient deficiencies. Family HX unremarkable. HEENT S. Denies any unusually frequent or severe H/A. No hx of head injury, dizziness, or syncope. Denies frequent or severe H/As, dizziness, or vertigo. No neck pain, limitation of motion, lumps or swelling. Vision reported good with no recent change. No eye pain, no inflammation, no discharge, no lesions. Wears no corrective lenses. Vision tested 1 yr ago, test for glaucoma at that time abnormal. States hearing is good, no earaches, infections, discharge, hearing loss, tinnitus, or vertigo. No work or leisure hazards. No hx. of discharge, sinus problems, obstruction, epitasis, or allergy. Colds 1-2/yr mild. No mouth pain, bleeding gums, dysphasia, or hoarseness. No apparent difficulty swallowing, or speaking. Occasional sore throat with colds. Tonsillectomy, age 8. Visits dentist annually; flosses and brushes daily. No dental appliance. O: Face-symmetric, no weakness or involuntary movements. Head-normocephalic, no lumps, lesions, or tenderness. No ptosis. Conjunctiva clear. Sclera white. No lesions. EOMs intact. No masses, lesions, tenderness, discharge. PERRLA. Nares patent. No septal deviation or perforation. Whispered words heard bilaterally. Mucosa and gingivae pink, no masses or lesions. Teeth in good repair. Uvula rises in midline on phonation. Tonsils not present. Mucosa pink. Tongue protrudes in midline. NECK S: No past hx of stroke, seizures, alcoholism, drug use, or meningitis. Denies neck pain or swelling. O: Carotids 2+ & equal bilaterally, no bruits. No significant lymphadenopathy or masses, trachea midline. Neck-full ROM, no pain, symmetric, shoulder shrug & head movement intact & = bilaterally. Turgor < 2 seconds. LUNGS & THORAX S: No cough or chest pain with breathing. Dyspnea on exertion; rates dyspnea as 7/10 on Borg dyspnea scale. No past hx of respiratory diseases. Has 1-2 colds/yr. Smokes cigarettes 2 PPD x 20 years. Last TB test 4 yrs ago neg. Never had chest x-ray. O: AP<transverse diameter. Respirations 16/min; relaxed and even. Chest expansion symmetrical. Resonant to percussion over lung fields. No adventitious sounds bilat. HEART S: Denies chest pain, dyspnea, orthopnea, cough, fatigue, edema, leg cramps, and skin changes. No past hx of cardiac or vascular problems. Family history: father & grandfather died in their 40s of heart attacks. Personal habits: diet balanced in 4 food groups, smokes 1 PPD x 15 yrs. 1-2 glasses wine on weekends, exercises 3x/wk with brisk walk. Last ECG 2 years PTA, result normal. O: PMI 5 ICS @left MCL, no significant pulsations, heaves, or thrills, S1 loudest at Mitral & S2 loudest at Pulmonic; no extra sounds, clicks, gallops or murmurs noted. Apical - radial and apical - carotid pulses 2+ regular, & equal bilaterally at 84 BPM. ABDOMEN
th

S: No hx of abd disease or surgery. Denies recent bowel changes, usually has 1 formed BM/day. Denies abd paid, N & V. O: Abd flat, symmetric with no apparent masses upon inspection. Skin smooth with no striae, scars or lesions. Bowel sounds normoactive; no hums or bruits. Tympany noted upon percussion in all 4 quadrants. Soft, no tenderness, guarding, or masses upon light palpation. UPPER EXTREMITIES S. No hx of skin disease, no present change in pigmentation or in nevi, no pruritis, bruising, rash, or lesions. Denies tremors, weakness, numbness, tingling. States no change in hair color, texture, or distribution. No change in nails. No work related skin hazards. Uses sun block cream when outdoors. O. Skin pink, warm to touch, dry smooth, no edema, no bruises, no lesions. Hair: normal distribution & texture, no scaling noted; cap. refill < 2 seconds; no clubbing or deformities. Pulses 82 BPM; 2+ bilat, regular. Hand grip strength grade 5 & equal bilaterally. LOWER EXTREMITIES S: States no hx. of muscle, bone, or joint disease. No hx. of trauma or deformities. No joint pain, stiffness, swelling, or limitation. No muscle pain or weakness. Usually able to manage ADLs and IADLs with no physical limitations. Occupation involves no musculoskeletal risk factors. Exercise pattern is minimal. O. Skin pink, warm to touch, dry smooth, no edema, no bruises, no lesions. Hair: normal distribution & texture, no scaling noted; toenails thickening; cap. refill < 2 seconds. No tenderness to palpation of joints; no heat, swelling, or masses. Joints and muscles symmetric; no edema, swelling, masses, or deformity. Full ROM; movement smooth, no crepitance, no tenderness. Negative Homans. Muscle strength = 5 on a 0-5 scale. Skin sensation intact at all dermatome levels. Negative Babinski sign. GU S: Last BM this am. dark brown, mod amt, formed. Urine clear, straw colored, no odor.

A. Head (Skull, Scalp, Hair) 1. Observe the size, shape and contour of the skull. 2. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions. 3. Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so. (wear gloves if necessary) 4. Observe and feel the hair condition. Normal Findings: Skull Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation. Scalp Lighter in color than the complexion. Can be moist or oily. No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation. Hair Can be black, brown or burgundy depending on the race. Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry.

B.

Face 1. Observe the face for shape. 2. Inspect for Symmetry. a. Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes. b. Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal. c. If both are met, then the Face is symmetrical 3. Test the functioning of Cranial Nerves that innervates the facial structures a. CN V (Trigeminal)

1.

Sensory Function Ask the client to close the eyes. Run cotton wisp over the fore head, check and jaw on both sides of the face. Ask the client if he/she feel it, and where she feels it. Check for corneal reflex using cotton wisp. The normal response in blinking.

2. Motor function Ask the client to chew or clench the jaw. The client should be able to clench or chew with strength and force. b. CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue). Place a sweet, sour, salty, or bitter substance near the tip of the tongue. Normally, the client can identify the taste. 2. Motor function Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks. Normal Findings: Shape maybe oval or rounded. Face is symmetrical. No involuntary muscle movements. Can move facial muscles at will. Intact cranial nerve V and VII B. Eyebrows, Eyes and Eyelashes

D. E. F. G. H. I. J. K.

Eye lids and Lacrimal Apparatus Conjuctivae Sclerae Cornea Anterior Chamber and Iris Pupils Cranial Nerve II (optic nerve) Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)

L.

Ears

M. Nose and Paranasal Sinuses N. O. P. Q. R. S. Cranial Nerve I (olfactory Nerve) Neck Thorax ( Cardiovascular System) Breast Abdomen Extremities