Nursing Assessment Head-to-Toe Physical Assessment in Pictures (Step by Step) PDF

 
Nursing Assessment
Head-to-Toe Physical Assessment in Pictures

Head to Toe Assessment Checklist

General Assessment
Body Structure/Mobility
Behavior
Health History
Vital Signs
Height Weight
Pulse Rate
Respirations
Temperature
Blood Pressure
Pain

Integumentary
Inspect: color, moisture, hair, rashes, lesions, pallor, edema
Palpate: temperature, turgor, lesions, edema, texture
Scalp
Inspect: shape, symmetry
Palpate: tenderness, deformity
Nails
Inspect: shape, color
Palpate: capillary refill

Head
Inspect: symmetry, shape, size, uniformity

Neck
Inspect: symmetry, lesions, scars
Palpate: tenderness, lymph nodes, thyroid gland, TMJ

Eyes
Inspect: interior and exterior, visual fields, acuity, reflexes

Ears
Inspect: color, shape, symmetry, interior inspection
Palpate: tenderness, deformity

Nose
Inspect: shape, symmetry, interior inspection
Palpate: frontal sinus, maxillary sinuses

Mouth and Throat
Inspect: exterior and interior

Thorax and Lungs (anterior and posterior)
Inspection: respiration quality, symmetry, deformity, tracheal location
Palpation: tenderness, fremitus, chest expansion
Percussion: percussive tones, diaphragmatic excursion
Auscultation: breath sounds and quality
Heart and Great Vessels
Inspection: jugular venous pulse
Palpate: pulses, PMI
Auscultate: heart sounds (bell and diaphragm)
Peripheral Vascular System
Inspect: color, edema
Palpate: temperature, edema

Abdomen
Inspect: discomfort, uniformity, color, symmetry, scars, hernia, peristalsis,
pulsations
Auscultate: bowel sounds, bruits
Percussion: four quadrants, liver, spleen, renal tenderness
Palpation: light to deep, liver, spleen, aorta, rebound tenderness, fluid wave

Musculoskeletal
Inspection: asymmetry, deformity, atrophy
Palpation: major joints, tenderness, deformity, range of motion

Neurological
Inspect: mental status (health history), cranial nerves, coordination,
movement, senses
Palpate: motor strength, muscle tone, reflexes, senses
Genitourinary
Inspect: general appearance, lesions, scars
Palpate: breast exam, testicular exam, prostate exam, vaginal exam, Pap
smear

Lymphatic
Palpate: assess lymph node locations
Integumentary
The outermost layer of the skin is called the epidermis. The next layer is the dermis and below that is
the subcutaneous layer of fat. Several important glands secrete fluids towards the skin. There are
two types of sweat glands. The apocrine sweat glands open into the hair follicles. They respond
specifically to emotion or arousal. They begin functioning during puberty. The eccrine sweat glands
secrete directly to the skin surface. Their main purpose is the regulation of body temperature. The
sebaceous glands secrete a lipid substance into hair follicles.
Hair is a string of proteins that grows from a follicle in the dermis layer of the skin. Hair is made of
3 layers the medulla in the center, the cortex, and then the cuticle.