1
Running Head: Head to Toe Assessment 1
Head to Toe Assessment
Jharana Khadka
South University Online
NSG 3012, Principles of Assessment for RNs
Week 4, Project 2
Professor Dr. Lisa Dabbs
Date: 11/03/2018
,2
Head to Toe Assessment
Physical examination is a medical examination by a healthcare professional to
determine the individual’s health, identify risk factors for disease, and devise strategies for
disease prevention. I conducted the physical examination of one my patient. Her name is Mrs.
Rodriguez 48 years female. She came to the hospital due to shortness of breath, cough, and
fever. When I took the health history, she stated that she has a past medical history of COPD and
HTN. She stated that has lifestyle risk factors which include a 19 years history of smoking 3
pack of cigarettes a week and she also drinks half a bottle of vodka per day. She is working in a
hotel as a sweeper. Her chief complaint is shortness of breath with exertion, productive cough
and mild fever. No past surgical history. Family history includes mom has a history of HTN,
HLD and breast cancer. Patient has no drug allergies. Patient home medicine includes
Amlodipine 5mg BID, Symbicort inhaler. Before starting a physical examination, we have to
gather all supplies or equipment include hand sanitizer, gloves, scale, stethoscope, thermometer,
pulse oximetry, penlight, otoscope, tuning fork, tongue depressor, tape measure, reflex hammer,
cotton ball, alcohol wipes, sphygmomanometer, and Snellen chart.
Techniques of Physical Assessment
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
GENERAL INSPECTION
➢ Physical Appearance and Hygiene: patient appears unkept and odorous.
➢ Body Structure and Position: patient looks malnourished, anorexic, with a barrel chest
while sitting in a tripod position and performing pursed lip breathing
➢ Body Movement: unbalance gait, slow walking, uncoordinated and trimmers noted
, 3
Head to Toe Assessment
➢ Emotional and Mental Status and Behavior: Patient alert and oriented to person, place
time and situation. Patient displays anxiety and restless behavior by continuously
pacing back and forth and tapping feet.
MEASUREMENT OF VITAL SIGNS, HEIGHT AND WEIGHT
• Temp.= 101.4 ˚F
• Pulse= 110b/min
• Resp.= 26/min
• B. P= 146/92 mm of hg
• Oxygen Saturation = 87% without oxygen
• Weight = 95lbs and Height = 5’3”
INTEGUMENTARY SYSTEM (skin, hair and nails)
Inspection and palpation
First, I inspect the condition and distribution of body hair and the integrity of the scalp. I
assess the hair I checked for distribution, thickness, texture, and lubrication of hair. I also
inspect for infection or manifestation of the scalp. I examined her face to assess for
blemishes and color while palpating her forehead to check for oiliness or a fever. Upon
assessing her arms, I assess for cuts and bruises. I assessed the nails for shape, contour,
consistency, color, thickness, and cleanliness. The back of her hand was used to assess
for skin turgor while the palm was assessed for coolness. I inspected the trunk for
discoloration or wounds such as sacral ulcers. Upon assessing the lower extremities, I
, 4
Head toinspected
Toe Assessment
the skin for dependent edema, bruises, cellulitis, discoloration, dryness,
weeping blisters or wounds such as ulcers.
Running Head: Head to Toe Assessment 1
Head to Toe Assessment
Jharana Khadka
South University Online
NSG 3012, Principles of Assessment for RNs
Week 4, Project 2
Professor Dr. Lisa Dabbs
Date: 11/03/2018
,2
Head to Toe Assessment
Physical examination is a medical examination by a healthcare professional to
determine the individual’s health, identify risk factors for disease, and devise strategies for
disease prevention. I conducted the physical examination of one my patient. Her name is Mrs.
Rodriguez 48 years female. She came to the hospital due to shortness of breath, cough, and
fever. When I took the health history, she stated that she has a past medical history of COPD and
HTN. She stated that has lifestyle risk factors which include a 19 years history of smoking 3
pack of cigarettes a week and she also drinks half a bottle of vodka per day. She is working in a
hotel as a sweeper. Her chief complaint is shortness of breath with exertion, productive cough
and mild fever. No past surgical history. Family history includes mom has a history of HTN,
HLD and breast cancer. Patient has no drug allergies. Patient home medicine includes
Amlodipine 5mg BID, Symbicort inhaler. Before starting a physical examination, we have to
gather all supplies or equipment include hand sanitizer, gloves, scale, stethoscope, thermometer,
pulse oximetry, penlight, otoscope, tuning fork, tongue depressor, tape measure, reflex hammer,
cotton ball, alcohol wipes, sphygmomanometer, and Snellen chart.
Techniques of Physical Assessment
1. Inspection
2. Palpation
3. Percussion
4. Auscultation
GENERAL INSPECTION
➢ Physical Appearance and Hygiene: patient appears unkept and odorous.
➢ Body Structure and Position: patient looks malnourished, anorexic, with a barrel chest
while sitting in a tripod position and performing pursed lip breathing
➢ Body Movement: unbalance gait, slow walking, uncoordinated and trimmers noted
, 3
Head to Toe Assessment
➢ Emotional and Mental Status and Behavior: Patient alert and oriented to person, place
time and situation. Patient displays anxiety and restless behavior by continuously
pacing back and forth and tapping feet.
MEASUREMENT OF VITAL SIGNS, HEIGHT AND WEIGHT
• Temp.= 101.4 ˚F
• Pulse= 110b/min
• Resp.= 26/min
• B. P= 146/92 mm of hg
• Oxygen Saturation = 87% without oxygen
• Weight = 95lbs and Height = 5’3”
INTEGUMENTARY SYSTEM (skin, hair and nails)
Inspection and palpation
First, I inspect the condition and distribution of body hair and the integrity of the scalp. I
assess the hair I checked for distribution, thickness, texture, and lubrication of hair. I also
inspect for infection or manifestation of the scalp. I examined her face to assess for
blemishes and color while palpating her forehead to check for oiliness or a fever. Upon
assessing her arms, I assess for cuts and bruises. I assessed the nails for shape, contour,
consistency, color, thickness, and cleanliness. The back of her hand was used to assess
for skin turgor while the palm was assessed for coolness. I inspected the trunk for
discoloration or wounds such as sacral ulcers. Upon assessing the lower extremities, I
, 4
Head toinspected
Toe Assessment
the skin for dependent edema, bruises, cellulitis, discoloration, dryness,
weeping blisters or wounds such as ulcers.
