Welcome to part three of the series on how to do an awesome head to toe nursing assessment. If you missed the previous posts, you can find them here:
Before we dive into the physical assessment piece, there are a few terms you need to be familiar with: inspection, auscultation, percussion, and palpation (say that three times fast!)
1. Inspection includes everything you can visually see about the patient. This includes things like skin tone, respiratory effort, and eye movement. Basically, anything you notice without actually touching the patient.
2. Auscultation is the act of listening to the patient. Using your stethoscope, you will listen to the patients heart, lungs and belly. Make sure your stethoscope is on! Yeah…I’ve made that mistake once…okay, maybe four times.
3. Percussion is when you tap your fingers along the patients body. This helps you notice solid, fluid or gas filled areas, and determine the size, shape and location of organs. For this technique, you will touch the area you need to assess with the pad of your middle finger of your non-dominant hand. Then with you dominant hand, you will gently tap your middle finger and listen to the tone it makes. If the tone is higher pitched (tympany), the area is gas or air filled, such as gas in the intestines. If the tone is lower pitched (dull), the area is solid, such as the liver.
4. Palpation is when you press your hands against the patients body. This helps you notice skin temperature, skin moisture, tender areas, and lumps or bumps. Make sure to wear gloves if the patient’s skin is moist or if they have any skin conditions such as rashes or wounds.
The head to toe assessment is made up of all of these parts. For each section of the nursing assessment, you will use at least one of these techniques.
The first section of the physical head to toe assessment is to assess the patients head, neck and skin.
Each of these questions may lead into more questions, so be prepared to dive a little bit deeper in some of these areas. Ask yourself or the patient the following questions:
1. Is their face symmetrical?
2. Are there any obvious wounds, scars, or abnormalities?
3. How much hair do they have?
4. Is their hair thin or thick?
5. Is their hair evenly distributed?
Gently pull up and down on their eyelids.
6. Is their conjunctiva pink, moist and intact?
7. Is their sclera white and intact?
8. Do they wear glasses or contacts?
9. Do they have any problems with their vision?
10. Have they had any eye surgeries or treatments?
Use your penlight to assess their pupils.
11. Are their pupils equal, round, reactive to light, and accommodation (PERRLA)?
Carefully fold the pinna forward to look behind their ear.
12. Is their skin intact?
Use your penlight to look inside the ear canal.
13. Is there any earwax or other discharge in the ear canal?
14. Can they hear you when you talk?
15. Do they wear hearing aids or use other hearing devices?
16. Do they have any congestion?
17. Are they sneezing?
18. Is there any discharge from their nose?
Use your penlight to look in their nose.
19. Are there any lesions?
20. What color is their oral mucosa?
21. Is their mouth moist or dry?
22. Are their lesions, bumps, or patches?
23. Do they have all of their teeth?
24. Are their teeth intact, rotted or chipped?
25. Do they wear dentures (partial or full)?
Gently palpate their neck.
26. Is their neck symmetrical or deviated?
27. Are there any lumps or bumps?
28. Are there any tender or painful areas?
29. Can they look left, right, up and down for full range of motion?
Gently palpate their skin.
30. Is their skin moist or dry?
31. Is their skin cool or warm?
32. Is their skin color appropriate for their ethnicity, dusky, pink, blue, or gray tinged?
33. Is their skin intact? (Remember: if they have an IV site, their skin is not intact.)
Gently pinch their skin at their clavicle or the back of their hand.
34. Does the skin stay tented?
35. Are their nails white, yellow, brown or blue?
36. Are their nails rounded and clean?
Carefully press on their fingernails.
37. How long does it take for the blood to return under their nail beds? (less than 3 seconds or greater than 3 seconds)
Be sure to come back for next weeks post on how to assess the respiratory system like a boss! Seriously, girlfriend, you are going to be a nursing assessment expert! Just be prepared for all your friends to find out what your secret to all those A’s is.
Comerford, K. C., & Hodgson, B. E. (2013). Assessment made incredibly easy. Ambler, PA: Lippincott Williams & Wilkins.