Head to Toe Physical Assessment

Question 1

How many critical elements are there?

Answer 1

11

Question 2

List all the critical elements by number.

Answer 2

1. Follow Standard Protocol
2. Vital Signs
3. Head
4. Upper extremities
5. Thorax
6. Assess Lungs
7. Assess Heart
8. Abdomen
9. Lower Extremities
10. Check & Note
11. Document

Question 3

Elements of standard protocol.

Answer 3

1. Handwashing
2. ID
3. Privacy
4. Assess symmetry
5. Skin integrity
6. Pain/problems in all areas

Question 4

Elements of Head Assessment.

Answer 4

1. Inspect head symmetry and skin integrity
2. Assess mental status (Alert and Oriented x5 – person, place, time, situation, follows commands.)
3. Assess PERRLA (Pupils Equal, Round, Reactive to Light, and Accomodation)
4. Palpebral conjuctiva
5. Inspect and ask about soreness in mouth and throat.
6. Assess neck for JVD.

Question 5

Elements of Upper Extremity assessment

Answer 5

1. Assess color and temperature with dorsum of hands.
2. Assess & compare muscle strength - grips, pushes and pulls.
3. Palpate both radial pulses.
4. Assess capillary refill.
5. Assess skin turgor on forearm or chest.

Question 6

Elements of Thorax Assessment

Answer 6

1. Sit patient up, adjust gown or clothing for modesty.
2. Inspect ease of breathing and thoracic symmetry.
3. Inspect for lifts or heaves.
4. Ask about chest pain, shortness of breath, cough, sputum.

Question 7

Elements of Lung Assessment

Answer 7

1. Auscultate breath sounds using landmarks. Listen above diaphragm. Hold stethoscope directly on skin.
2. Back - auscultate alternate sides at least four times each side.
3. Front - auscultate alternate sides at least four times each side including RML. Stay above 6th rib medially, 8th rib laterally.
4. Sides - auscultate in at least 2 places on each side.

Question 8

Elements of Heart Assessment

Answer 8

1. Auscultate heart sounds A P E To Man
2. State and show location of each valve: Aortic, Pulmonic, Erbs, Tricuspid, Mitral
3. State rate and rhythm.
4. State where you can best assess rate & rhythm prior to giving a med. (apical pulse).

Question 9

Elements of Abdomen Assessment

Answer 9

1. Ask about pain or tenderness, palpate tender area last.
2. Cover chest, pull sheet down to top of pubis and gown up to reveal abdomen.
3. Ask about bowel and bladder elimation.
4. Inspect for symmetry and hernias. Have patient do a “crunch” if able.
5. Auscultate bowel sounds in each quadrant, start in RLQ.
6. Lightly palpate in all 4 quadrants in circular motion, 2-3 cm assess if soft or firm.
7. Ask if tender while palpating.

Question 10

Elements of Lower Extremities Assessments

Answer 10

1. Ask about calf pain or tenderness
2. Assess color, temperature of LE knees to feet with dorsum of hands.
3. Palpate: dorsalis pedis and post tibialis pulses.
4. Edema on top of foot, malleoli, shins.
5. Check nailbeds, capillary refill.
6. Assess muscle strength: ask to plantar/dorsi flex - push/pull against your hands.
7. Ask to wiggle toes, ask about numbness or tingling.

Question 11

Elements of Check & Note

Answer 11

1. Drains
2. Tubes
3. IV sites
4. O2

Question 12

What is the last critical element of a head to toe physical assessment?

Answer 12

Document.

Question 13

Elements of Vital Signs

Answer 13

1. Temperature
2. Pulse
3. Respirations
4. Blood Pressure
5. Pulse Oximetry
6. Pain