Head to Toe Assessment Validation Check Off Validation # 1 General Appearance (4 Things ~ Penny Loved Pappy’s Shirt) • • •
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State: Privacy has been provided for the client Note: Wash hands. Introduce myself. Explain that I will be completing a head to toe physical assessment on them today. Check: LOC ~ Name (Check ID band), Place, Time o State: A & O x 3, Facial expression, mood, and affect are appropriate. Dressed appropriately for the weather today. I previously checked VS and they were WNL. Has Ø C/O pain. Check: Posture & Mobility (just look as I am doing LOC) o State: Erect & moves all extremities freely. Check: Skin Color, Temp (Feel cheek w/back of hand), Turgor @ clavicle area), Cap Refill, & Speech. o State: Skin turgor is good without tenting. Capillary refill ≤ 2 seconds. Speech is also clear.
Head & Face (4 Things ~ Show Family The Stars) • •
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Check: Scalp, Hair, & Cranium o State: No nodules palpated, hair clean & shiny, Ø infestion. Check: Facial Movements ~ Cranial Nerve VII (smile, frown, close eyes tightly, lift your eyebrows, show me your teeth, puff out cheeks and then press out the air). o State: Facial movements symmetrical, Ø deficits observed. Check: Temporal Artery (palpate w/fingers between temple & front of ear) & Temporomandibular Joint (slide fingers to TMJ joint, client to open mouth, close mouth, and move jaw side to side). o State: Temporal artery palpated, pulse present. Ø Crepitus felt w/TMJ movement. Check: Sinuses (Place thumbs below eyebrows, press ↑ and under the eyebrow, then over maxillary sinuses ↓ cheek bones w/both thumbs. Ask client if any of the areas I pressed on were tender). o State: No tenderness
Eyes (2 Things ~ EC) Page 1 of 7
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Check: Eyebrows & Eyelids (look, have client look up, use thumbs to pull down on lower lids, look @ sclera @ the same time). o State: Eyes are symmetrical, Ø ptosis (drooping) of eyelids. Conjunctiva is pink and moist. Sclera is white and smooth. Check: Cornea & Lens of eyes (get penlight, stand at side of client, shine light from side across cornea, look for smoothness & clarity; then shine light @ slight angle into pupils & watch for constriction; then put my finger in front of client face, have them look @ object across the room, then back @ my finger). o State: PERRLA stands for pupils equal, round, reactive to light, and accommodating. Pupils round, equal in size, reactive to light, constrict in response to light, and accommodating bilaterally. Ø cloudiness noted.
Ears (5 Things ~ Penny Watched Rachel’s White Igloo) •
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Check: (from front, check Pinna position – top of ear aligned w/corner of eye; vertically, Ø more than 10 degree variation from imaginary line drawn from top to bottom of ear; look @ skin of pinna, tragus, and mastoid). o State: Top of pinna is aligned w/corner of eye. ≤ 10 degree variance vertically. Pink. Ø nodules, drainage, or tenderness. Check: Whispered Voice Test: (close R ear, stand 1 to 2 ft. behind the client, cover my mouth, whisper 3,4,5 into L ear, ask client if can tell me what I said ~ if incorrect, try again, if 3/6 is correct = pass; now repeat, close L ear, but now whisper love your dog in R ear, ask client if can tell me what I said). Check: Rinne ~ 1st Bone Conduction (BC), then 2nd Air Conduction (AC): (get tuning fork, explain to tell me when can no longer hear sound, then again when it is moved, strike the tuning fork on my hand/knee, hold base/stem behind ear, then immediately turn the fork horizontally not touching ear while watching my watch ~ Normal = AC ≥ BC, if not test is +). o State: Air Conduction (AC) is ≥ than Bone Conduction (BC), so Rinne is WNL. Check: Weber: (explain doing a different test w/same instrument, tell me if able to hear it the same in ears bilaterally, use tuning fork, strike it again, hold base/stem on middle top of head). o State: No sensorineural hearing loss. Check: Inner Ear (get otoscope, put cover on it, turn on the light, tilt the client’s head away from me, pull pinna ↑ & back, don’t release until speculum out, hold otoscope upside ↓ w/back of hand braced on client cheek, observe canal as inserting, put eye on otoscope, rotate it toward the nose; visualize tympanic membrane ~ R drum @ 5-o’clock, L drum @ 7-o’clock; remove otoscope, release pinna; repeat on other ear). o State: Tympanic membrane is pearly grey. Ø drainage or exudate noted. Page 2 of 7
Nose, Mouth, & Throat (2 Things ~ NM) •
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Check: Nostril & Nasal Septum (shine penlight and look in both nostrils, look for obstruction, ask person to close each side of nostril by pressing finger on side of nose, breathe in and out, repeat on other side) o State: Patent without drainage or obstruction noted. No deviation of septum noted. Check: Mouth ~ Tongue, Uvula, Oral Mucosa, Tonsils, Teeth (ask person to open mouth wide & say AHH, shine penlight to back of throat on tonsillar area, observe tonsil for grade 1+ to 4+, look at everything else in throat and mouth). o State: Tongue is pink and moist, not lesions; Uvula is midline and rises equally; Oral Mucosa is pink and moist, no lesions; Tonsils are 2+ no redness or exudate noted; Teeth are present w/none missing.
Neck (7 Things ~ Nick Led Celia Through The Jewelry Ringer) •
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Check: Neck o State: The head position is centered in the midline, accessory neck muscles are symmetric, the head is held erect and still. Check: Lymph Nodes (use finger tips and circular motion w/gentle pressure, be able to palpate Preauricular – in front of ears, Occipital – behind the ear, Submental – under chin, Submandibular – behind submental, Posterior Cervical – down the side of the neck, Supraclavicular – around the clavicle area). o State: No lymph nodes palpated. Normal nodes feel movable (mobility), discrete (delimitation), soft (consistency), and non-tender (tenderness). Check: Carotid Pulse (one side at a time) o State: Present, Bilaterally 2+ Check: Trachea o State: Trachea is midline. Check: Thyroid Gland (stand behind person, use fingers to gently push trachea toward the other side, ask person to swallow, thyroid moves up w/trachea and larynx as person swallows, w/fingers of the other hand, palpate thyroid, and do the same to palpate other side of thyroid). o State: No nodules or abnormalities palpated. Check: Jugular Vein Distention (JVD) (have person lie down on bed, elevate bed 30 to 45 degree, remove pillow, stand on one side, have person to turn head slightly toward opposite side, probably can’t see, but if can, observe for pulsations). o State: No JVD
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Check: ROM and Muscle Strength (ROM: have person touch chin to chest (Flexion); lift chin toward the ceiling (hyperextension); touch each ear toward each shoulder (Lateral bending); Strength: person to turn head toward side w/hand on cheek pressing for resistance, then do other side). o State: Full ROM
Validation # 2 Chest (4 Things ~ CAHP) •
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Check: Chest (color; place hands on posterior – back chest wall w/thumbs at level of T9 or T10 about middle of back, press in and slide hands toward each other to pinch up a small fold of skin between thumbs, have person take a deep breath – should move symmetrically). o State: S1 – heard loudest @ apex. S2 – heard loudest @ base. Color is pink. Transvers diameter is ≥ than 2 x the AP diameter. Chest expands symmetrically. Neck muscles and trapezius muscles developed normally & no other accessory muscles used, relaxed posture. Check: Anterior Breath Sounds (use side to side comparison) & Rate & Rhythm of Respirations (start @ apecies in the supraclavicular area – on the right side, then move to left, then down, etc. x 6 areas. R = 3 lobes, L = 2 lobes; count respirations while stethoscope still in place, observe rhythm). o State: Lungs clear; breath sounds auscultated throughout lung fields. Resp. 20 w/regular rate & rhythm. Check: Heart Sounds (use 5 auscultatory area – All Pigs Eat Too Much for Aortic – R side ↓ clavicle – access where ribs are, count down to 2nd intercostal space, Pulmonic – L side, next to sternum, across from Aortic area – 2nd intercostal space, Erb’s Point – below the pulmonic area on L side, 3rd intercostal space, Tricuspid area – L side at bottom of sternum area, under Erb’s Point, 5th intercostal space, and Mitral Valve (Apex area – PMI, bottom of sternum, L side, to the left and slightly below tricuspid area, still on 5th intercostal space. Actually making a Z pattern starting @ Aortic area. Find apical pulse by starting at the top of the sternum, move fingers ↓ L side of sternum to 5th intercostal space, right below the breast. Place stethoscope here – PMI “Point of Maximum Impulse”). Page 4 of 7
State: Apical pulse rate is 60, regular rhythm w/no murmurs heard. Check: Posterior Chest (look at shape and configuration) o State: Spine is straight. Thorax & Scapulae are symmetrical. o
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Upper Extremities (5 Things ~ HNRRS) •
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Check: Hands & Arms (color, temperature by feeling w/dorsa of hand, and turgor by pinching forearm) o State: Skin pink, warm, & dry. Turgor is good. Check: Nails (clubbing - + indicates O2 problem like lung cancer or bronchiectasis, ↓ 160 is normal, ↑ 180 is +, cap refill) o State: No clubbing; Cap refill ≤ 2 seconds. Check: Radial & Brachial Pulses (palpate radial pulse bilaterally on thumb side of wrist and compare. Palpate brachial pulse bilaterally in the bend of arm and compare). o State: Pulses strong & equal biliaterally. Check: ROM ~ Arms, Hands, Shoulders (Shoulder – Flexion to Hyperextension – have person put arms @ sides w/elbows extended then move both arms forward and ↑ in wide vertical arcs, then move them back as far as possible. Internal/External Rotation (Potter & Perry) – arms straight out, elbow bent up w/hands ↑, then hands pointed ↓ w/elbow remaining bent. Abduction/Adduction – w/arms @ sides and elbows extended, have person raise both arms in side arcs and ↑ to touch palms together above head. Arms – Flexion/Extension – have person bend and straighten elbow. Pronation – palms ↓. Supination – palms ↑. Hands – Extension/Flexion – straighten fingers out, then bend them ↓. Ulnar/Radial Deviation – move hand at wrist side to side, spread fingers apart, then make a fist, touch the thumb to each finger.) Check: Strength Resistance ~ Arms, Shoulders, Grips – (Arms – stabilize person’s arm w/one of my hands, arm bent @ elbow, then put pressure on the other hand just below the wrist while the person attempts to raise, then reverse and have person press toward me while I resist. Shoulders – have person shrug shoulders against my resistance by pressing ↓ on the shoulder. Grips – have person squeeze both my hands. o State: Handgrips strong and even.
Abdomen (4 Things ~ IAPP) •
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Check: Inspection (person lie ↓, get eye level w/abdomen for observation. Observe for contour – flat, rounded, scaphoid, protuberant; look for symmetry.) o State: Abdomen flat & symmetrical Check: Auscultate Bowel Sounds (listen to 4 quadrants starting @ RLQ). o State: Bowel sounds present in all 4 quadrants (if absent, listen 5 min.)
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Check: Percuss & Identify Tones (start @ RLQ, use middle finger and tapping w/middle finger of other hand. Tympany should be heard throughout. o State: Bowel sounds active & Tympany heard in all 4 quadrants. Check: Palpation (lightly palpate starting in RLQ) o State: Abdomen soft, no abnormalities palpated.
Lower Extremities (6 Things ~ Lisa Passed Harry’s Cute Rabbit Singing) •
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Check: Legs & Feet (color, temperature w/back of hand, edema by pressing fingers to skin over ankles for 5 seconds, then releasing – check for 1+, 2+, 3+, or 4+ pitting edema) o State: Legs are pink and even colored, temp is warm & dry. 1+ non-pitting edema in ankles. Check: Posterior Tibia & Dorsalis Pedis Pulses (Posterior - @ inner aspect of ankle in groove between the malleolus & the Achilles tendon. Can dorsiflex ankle if problem palpating; Dorsalis Pedis – top of foot usually lateral to and parallel w/extensor tendon of big toe). o State: Femoral pulse is palpated just below the inguinal ligament halfway between the pubis and anterior superior iliac spines – groin area. Check: Homan’s Sign (person lies down, dorsiflex foot toward the tibia, repeat on other leg. If pain present = +). o State: If + result, can mean possible DVT Check: Cap Refill (pinch toes) o State: Capillary refill ≤ 2 seconds Check: ROM – Hips, Knees, Ankles, Feet (Hips – Flexion/Extension – should be lying down, raise one leg @ a time, and lower it, Abduction – Move leg sideways away from other leg, Adduction – bring leg back beside other leg, Internal/External Rotation - Flex one knee with foot on bed, Lean knee toward knee that is extended (Internal rotation), then have the person to lean knee as far as possible in opposite direction of other knee (External rotation), Knees - Flexion/Extension - In standing position, have person to bend their knee bringing foot behind them, then bring foot forward as far as possible (Hyperextension), Ankles - Have person point toes up (Dorsiflexion); Down (Plantar flexion), Turn foot inward (inversion) and turn foot outward (eversion), Have person flex and straighten toes). Check: Strength & Resistance of Legs & Feet (person should maintain knee flexion while I oppose by trying to pull the leg forward. Assess strength in feet, person should maintain dorsiflexion and plantar flexion against my resistance). o State: Full ROM, Muscle strength strong and symmetrical.
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Neurological & Musculoskeletal (8 Things ~ Gretchen Sold Rabid Rabbits For Brenda During Sabbath) •
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Check: Gait (Hot To Handle, heel-to-toe, walk on toes, then heels, Have person to walk 10 feet from you, turn and return. Note gait, balance, and coordination. Heel-to-toe walk - Have person to walk with toes touching heel of opposing foot. Have person to walk on heels for several steps then on toes for several tests). Check: Spine for Abnormalities (from side of person, observe curvature of spine and thoracic curve). o State: Spine straight, no abnormalities noted. Check: ROM in Spine (Have patient bend over (Flexion/Extension); Bend Side to side (Lateral bending); and Rotate o State: Full ROM Check: Romberg’s Test (person to stand w/feet together and arms by their side, close their eyes for 20 seconds, some swaying is normal) o State: If balance is lost = + test which could indicate a neurological disease). Check: Finger to Nose Test (hold arms out, touch nose, alternating sides and increasing speed). Check: Babinski Reflex (With handle of hammer, stroke up the lateral side of the sole of the foot and inward across the ball). o State: If toes curl = Plantar reflex; If toes flare = + Babinski if older than 24 months. Check: Deep Tendon Reflexes – “Peter Ate The Butter Biscuit” Patellar, Achilles, Triceps, Biceps, Brachioradial, (Patellar - Let the lower leg dangle, then strike the tendon directly just below the patella. Achilles - Have person sit on side of bed, feet dangling or if lying, flex one knee and support lower leg against the other. Dorsiflex the foot and tap the tendon. Repeat on other side. Triceps - Suspend upper arm by holding it just above elbow. Strike the triceps tendon directly just above the elbow. Biceps - Support person’s forearm on yours, Place your thumb on the biceps tendon and strike a blow on your thumb. Brachioradialis - Hold person’s thumb to suspend the forearms. Strike forearm directly about 2 to 3 cm above the radial styloid process. Repeat on other side). o State: Reflexes present. No abnormalities Check: Sensation to Sharp & Dull (Using object that is dull and one that is sharp, have person to close eyes touch foot of person with each and ask what he/she feels sharp or dull).
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