Head To Assessment
Head To Assessment
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
Head
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.
Extremities
Assessment Findings
Integumentary
Palpebral
Conjunctiva Shiny, smooth, pink
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