NSB - Head To Toe Assessment

Question 1

What are the 9 parts of the head to toe assessment?

Answer 1

Introduction
Orientation
Vital signs
Head & Face
Neck, Chest (Lungs) & Heart
Peripherals
Spine
Lower Extremities(hips, knees, ankles)
Abdomen

Question 2

What do you do when introducing yourself to a patient?

Answer 2

• Knock
• Introduce yourself
• Wash hands
• Provide Privacy
• Verify client ID & DOB
• Explain what you are doing (using non-medical language)

Question 3

How do you assess a patients “orientation”?

Answer 3

What is your name?
Do you know where you are?
Do you know what month it is?
Who is the current prime minister?
What are you doing here?
A&O X4 - Orientated to person, place, time, and situation.

Question 4

What are the “normal” vitals ranges?

Answer 4

Pulse: 60-100bpm
Blood Pressure: 120/80 mmHg
O2 Saturation: 95-100%
Temerpature: 36.0-37.5c
Respirations: 12-20 breaths per min

Question 5

What is the scale used to assess the strength of the pulse?

Answer 5

0 - Pulse is absent
1+ - Diminished
2+ - Normal
3+ - Full
4+ - Bounding, Strong

Question 6

When examining the patient what are the four methods used to assess their status and what is their order?

Answer 6

1. Inspect
2. Palpate
3. Percuss
4. Auscultate

Question 7

What are you examining when assessing the head & face?

Answer 7

Head - Inspect: Head/Scalp/Hair
- Palpate: Head/Scalp/Hair

Face - Inspect
- Check for symmetry
- To assess cranial nerve 7, check the following: Raise eyebrows
\: Smile
\: Frown
\: Show teeth
\: Puff out cheeks
\: Tightly close eyes

Eyes - Inspect external eye structures

• Inspect colour of conjunctiva & sclera
• PERRLA: Pupils Equal, Round, Reactive to light & Accommodation

Question 8

What are you examining when assessing the necks, chest (lungs) & heart?

Answer 8

Neck - Inspect & palpate

• Palpate carotid pulse
• Check skin turgor (under clavicle)

Posterior chest - Inspect
- Auscultate lung sounds in posterior and lateral chest: Note any crackles or diminished lung sounds.

Anterior chest - Inspect: Use of accessory muscles
: AP to transverse diameter
: Sternum configuration
- Palpate: Symmetric expansion
- Auscultate lung sounds -> anterior and lateral: Note any crackles or diminished breath sounds

Heart - Auscultate heart sounds ( A,P,E,T,M) with diaphragm and bell : Note any murmurs, whooshing, bruits, or muffled heart sounds

Question 9

What are the 5 areas for listening to the heart?

Answer 9

All People Enjoy Time Magazine
A: Aortic
P: Pulmonic
E: Erb's Point
T: Tricuspid
M: Mitral

Question 10

What are you examining when assessing the peripherals?

Answer 10

Upper extremities - Inspect & palpate

• Note any texture, lesions, temperature, moisture, tenderness, & swelling
• Palpate radial pulses bilaterally (Use the pulse strength scale)

Shoulder - Inspect, palpate, and assess

Elbows - Inspect, palpate, and assess

Hands & fingers - Inspect hands/fingers/nails

• Palpate hands and finger joints
• Check muscle strength of hands bilaterally: Does each hand grip evenly?

Question 11

What are you examining when assessing the spine?

Answer 11

• Have the client stand up (if able)
• Inspect the skin on the back
• Inspect: spinal curvature (cervical/thoracic/lumbar)
• Palpate spine
• Note any lesions, lumps, or abnormalities.

Question 12

What are you examining when assessing the lower extremities (hips, knees, ankles)?

Answer 12

Lower extremities - Inspect: Overall skin colouration
: Lesions
: Hair distribution
: Varicosities
: Oedema
- Palpate: Check for oedema(Pitting or non-pitting)
- Check capillary refill bilaterally (Normal <2-3 seconds)

Hips - Inspect & palpate

Knees - Inspect & Palpate

Ankles - Inspect & palpate
- Posterior Pulse (Use the pulse strength scale)
- Dorsal Pedis pulse bilaterally : Check strength bilaterally (Use the pulse strength scale)
: Dorsiflexion flexion against resistance

Question 13

What is capillary refill time?

Answer 13

Capillary Refill Time (CRT) is the time taken for capillary bed to regain it’s colour after pressure has been applied.

Question 14

What are you examining when assessing the abdomen?

Answer 14

The abdomen is assessed in a different order:
1. Inspect
2. Auscultate
3. Percuss
4. Palpate
If we were to percuss + Palpate before listening(auscultating), we would alter the bowel sounds. This would lead to inaccurate results.

- Inspect: Skin colour
\: Contour
\: Scars
\: Aortic Pulsations
- Auscultate bowel sounds: all 4 quadrants (start in RLQ and go clockwise)
- Light palpation: all 4 quadrants

Sound scale:
Absent: Must listen for at least 5 minutes to chart absent bowel sounds
Hypoactive: One bowel sound every 3-5 minutes
Normoactive: Gurgles 5-30 times per minute
Hyperactive: Can sometimes be heard without a stethoscope. Constant bowel sounds (> 30 sounds per minute)

Question 15

Important overall expectations of the head to toe exam

Answer 15

Positions and drapes client appropriately during exam ( gave client privacy)

Gave client feedback/instructions

Exhibits professional manner during exam, treated client with respect & dignity

Organised: Exam followed a logical sequence (order of exam “made sense”)