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Head To Assessment

Nursing assessment is the foundation of the nursing process. This physical assessment examines the client from head to toe, including integumentary, head, eyes, ears, nose, mouth, neck, lungs, heart, abdomen, and extremities. The client's skin, hair, nails, skull, face and other areas were examined and found to be normal, with no abnormalities observed.
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0% found this document useful (0 votes)
330 views10 pages

Head To Assessment

Nursing assessment is the foundation of the nursing process. This physical assessment examines the client from head to toe, including integumentary, head, eyes, ears, nose, mouth, neck, lungs, heart, abdomen, and extremities. The client's skin, hair, nails, skull, face and other areas were examined and found to be normal, with no abnormalities observed.
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Head to

Toe
Physical
Nursing assessment is an important step of the whole nursing process. Assessment can be called the
“base or foundation” of the nursing process. With a weak or incorrect assessment, nurses can create an
incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation.

Physical Assessment

Integument

 Skin: The client’s skin is uniform in color, unblemished and no


presence of any foul odor. He has a good skin turgor and skin’s
temperature is within normal limit.
 Hair: The hair of the client is thick, silky hair is evenly distributed and
has a variable amount of body hair. There are also no signs
of infection and infestation observed.
 Nails: The client has a light brown nails and has the shape of convex
curve. It is smooth and is intact with the epidermis. When nails
pressed between the fingers (Blanch Test), the nails return to usual
color in less than 4 seconds.

Head

 Head: The head of the client is rounded; normocephalic and


symmetrical.
 Skull: There are no nodules or masses and depressions when
palpated.
 Face: The face of the client appeared smooth and has uniform
consistency and with no presence of nodules or masses.

Eyes and Vision


 Eyebrows: Hair is evenly distributed. The client’s eyebrows are
symmetrically aligned and showed equal movement when asked to
raise and lower eyebrows.
 Eyelashes: Eyelashes appeared to be equally distributed and curled
slightly outward.
 Eyelids: There were no presence of discharges, no discoloration and
lids close symmetrically with involuntary blinks approximately 15-20
times per minute.
 Eyes
o The Bulbar conjunctiva appeared transparent with few
capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and
pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of
the iris are visible. The client blinks when the cornea was
touched.
o The pupils of the eyes are black and equal in size. The iris is
flat and round. PERRLA (pupils equally round respond to
light accommodation), illuminated and non-illuminated
pupils constricts. Pupils constrict when looking at near
object and dilate at far object. Pupils converge when object
is moved towards the nose.
o When assessing the peripheral visual field, the client can
see objects in the periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the
client coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance
of 14 inches.

Ears and Hearing


 Ears: The Auricles are symmetrical and has the same color with his
facial skin. The auricles are aligned with the outer canthus of eye.
When palpating for the texture, the auricles are mobile, firm and not
tender. The pinna recoils when folded. During the assessment of
Watch tick test, the client was able to hear ticking in both ears.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color.


There was no presence of discharge or flaring. When lightly
palpated, there were no tenderness and lesions
 Mouth:
o The lips of the client are uniformly pink; moist, symmetric
and have a smooth texture. The client was able to purse his
lips when asked to whistle.
o Teeth and Gums: There are no discoloration of the
enamels, no retraction of gums, pinkish in color of gums
o The buccal mucosa of the client appeared as uniformly pink;
moist, soft, glistening and with elastic texture.
o The tongue of the client is centrally positioned. It is pink in
color, moist and slightly rough. There is a presence of thin
whitish coating.
o The smooth palates are light pink and smooth while the
hard palate has a more irregular texture.
o The uvula of the client is positioned in the midline of the
soft palate.

 Neck:
o The neck muscles are equal in size. The client showed
coordinated, smooth head movement with no discomfort.
o The lymph nodes of the client are not palpable.
o The trachea is placed in the midline of the neck.
o The thyroid gland is not visible on inspection and the glands
ascend during swallowing but are not visible.

Thorax, Lungs, and Abdomen

 Lungs / Chest: The chest wall is intact with no tenderness and


masses. There’s a full and symmetric expansion and the thumbs
separate 2-3 cm during deep inspiration when assessing for the
respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.
 The spine is vertically aligned. The right and left shoulders and hips
are of the same height.
 Heart: There were no visible pulsations on the aortic and pulmonic
areas. There is no presence of heaves or lifts.
 Abdomen: The abdomen of the client has an unblemished skin and
is uniform in color. The abdomen has a symmetric contour. There
were symmetric movements caused associated with client’s
respiration.
o The jugular veins are not visible.
o When nails pressed between the fingers (Blanch Test), the
nails return to usual color in less than 4 seconds.

Extremities

 The extremities are symmetrical in size and length.


 Muscles: The muscles are not palpable with the absence of tremors.
They are normally firm and showed smooth, coordinated
movements.
 Bones: There were no presence of bone deformities, tenderness
and swelling.
 Joints: There were no swelling, tenderness and joints move
smoothly.

Nursing Assessment in Tabular Form

Assessment Findings

Integumentary

When skin is pinched it goes to previous


 Skin state immediately (2 seconds).
With fair complexion.
With dry skin
Evenly distributed hair.
 Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean fingernails and
 Nails toenails.
Convex and with good capillary refill
time of 2 seconds.
Rounded, normocephalic and
symmetrical, smooth and has uniform
Skull
consistency. Absence of nodules or
masses.
Assessment Findings

Symmetrical facial movement, palpebral


fissures equal in size, symmetric
Face
nasolabial folds.

Eyes and Vision


Hair evenly distributed with skin intact.
 Eyebrows Eyebrows are symmetrically aligned and
have equal movement.
 Eyelashes Equally distributed and curled slightly
outward.
Skin intact with no discharges and no
 Eyelids discoloration.
Lids close symmetrically and blinks
involuntary.
 Bulbar conjunctiva Transparent with capillaries slightly
visible

 Palpebral
Conjunctiva Shiny, smooth, pink

 Sclera Appears white.

 Lacrimal gland,
Lacrimal sac, No edema or tenderness over the
lacrimal gland and no tearing.
Nasolacrimal duct

Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which
 Clarity and texture is held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.
Blinks when the cornea is touched
 Corneal sensitivity through a cotton wisp from the back of
the client.
Pupils Black, equal in size with consensual and
direct reaction, pupils equally rounded
Assessment Findings

and reactive to light and


accommodation, pupils constrict when
looking at near objects, dilates at far
objects, converge when object is moved
toward the nose at four inches distance
and by using penlight.
When looking straight ahead, the client
can see objects at the periphery which is
done by having the client sit directly
facing the nurse at a distance of 2-3 feet.
Visual Fields The right eye is covered with a card and
asked to look directly at the student
nurse’s nose. Hold penlight in the
periphery and ask the client when the
moving object is spotted.
Able to identify letter/read in the
newsprints at a distance of fourteen
Visual Acuity inches.
Patient was able to read the newsprint at
a distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial
skin, symmetrical, auricle is aligned with
 Auricles the outer canthus of the eye, mobile,
firm, non-tender, and pinna recoils after
it is being folded.
 External Ear Canal Without impacted cerumen.

 Hearing Acuity Test Voice sound audible.

Able to hear ticking on right ear at a


 Watch Tick Test distance of one inch and was able to hear
the ticking on the left ear at the same
distance.

Nose and sinuses


Symmetric and straight, no flaring,
 External Nose uniform in color, air moves freely as the
clients breathes through the nares.
Assessment Findings

Mucosa is pink, no lesions and nasal


 Nasal Cavity septum intact and in middle with no
tenderness.
Symmetrical, pale lips, brown gums and
Mouth and Oropharynx
able to purse lips.
 Teeth With dental caries and decayed lower
molars

 Tongue and floor of Central position, pink but with whitish


the mouth coating which is normal, with veins
prominent in the floor of the mouth.

Moves when asked to move without


 Tongue movement difficulty and without tenderness upon
palpation.
Uvula Positioned midline of soft palate.
Present which is elicited through the use
Gag Reflex
of a tongue depressor.
Positioned at the midline without
Neck tenderness and flexes easily. No masses
palpated.
Coordinated, smooth movement with no
Head movement discomfort, head laterally flexes, head
laterally rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Not visible on inspection, glands ascend
 Thyroid Gland but not visible in female during
swallowing and visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
Spine vertically aligned, spinal column
 Spinal alignment is straight, left and right shoulders and
hips are at the same height.
With  normal breath sounds without
Breath Sounds
dyspnea.
 Anterior Thorax Quiet, rhythmic and effortless
respiration
Abdomen Unblemished skin, uniform in color,
Assessment Findings

symmetric contour, not distended.


Symmetrical movements cause by
Abdominal movements
respirations.
 Auscultation of bowel
With audible sounds of 23 bowel
sounds sounds/minute.

Without scars and lesions on both


Upper Extremities
extremities.
Lower Extremities With minimal scars on lower extremities
Equal in size both sides of the body,
smooth coordinated movements, 100%
Muscles
of normal full movement against gravity
and full resistance.
No deformities or swelling, joints move
Bones and Joints
smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Able to concentrate as evidence by
Attention span
answering the questions appropriately.
A total of 15 points indicative of
Level of Consciousness
complete orientation and alertness.
Motor Function
Gross Motor and Balance
Has upright posture and steady gait with
 Walking gait opposing arm swing unaided and
maintaining balance.
Maintained stance for at least five (5)
Standing on one foot with eyes closed
seconds.
Maintains a heel toe walking along a
Heel toe walking
straight line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper
Extremities
Repeatedly and rhythmically touches the
Finger to nose test
nose.
Alternating supination and pronation Can alternately supinate and pronate
Assessment Findings

of hands on knees hands at rapid pace.


Finger to nose and to the nurse’s
Perform with coordinating and rapidity.
finger
Fingers to fingers Perform with accuracy and rapidity.
Rapidly touches each finger to thumb
Fingers to thumb
with each hand.
Fine motor test for the Lower
Extremities
Able to discriminate between sharp and
Pain sensation dull sensation when touched with needle
and cotton.

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