Physical Assessment/Head to Toe

Question 1

Step 1

Answer 1

perform hand hygiene

Question 2

Step 2

Answer 2

introduce myself to the patient and identify the patient.

Question 3

Step 3

Answer 3

state my purpose, “today I am going to be doing a physical assessment.” and Ensure the patient’s privacy by securing a screen to cover them.

Question 4

Step 4:

Answer 4

assess the patient’s general physical appearance and hygiene.

“my patient is sitting up straight, they look clean and put together”

Question 5

Step 5:

Answer 5

assess the patient’s consciousness and mental status
“do you know what month we’re in?” “do you know what day it is?”

Question 6

Step 6:

Answer 6

assess my patient’s pain status

“Are you in any pain?”
if they say yes, “on a scale from 1 to 10, 1 being the weak and 10 being strong, what is your pain?”

Question 7

Step 7:

Answer 7

check IV lines-IV site, tubing dates, IV solutions, IV infusion rates, etc

Question 8

Step 8:

Answer 8

inspects head and face for color, and symmetry. lesions, and distribution of facial hair. Note facial expressions. Note drainage or discharge from orifices.

Question 9

Step 9:

Answer 9

inspects external eye structures (eyelids, eyelashes. eyeball, and eyebrows, and cornea, conjuntiva and sclera. Note color, edema, symmetry, alignment. Ask my patient about their vision, do they use glasses.

Question 10

Step 10:

Answer 10

examines the pupils for quality of size, shape, and reaction to light by darkening the room. Shine a light on the eyes. The pupil should constrict in the light and return to normal size.

Question 11

Step 11:

Answer 11

Tests for pupillary accommodation & convergence as patient focuses on an object brought close to the nose

Question 12

Step 12:

Answer 12

Inspects the external nose, checks for patency, any drainage, and notes any abnormalities

Question 13

Step 13:

Answer 13

Inspects the lips, oral mucosa & tongue using a penlight.

Question 14

Step 14:

Answer 14

Inspects the neck for jugular vein distention (HOB at 30-45 °).

Question 15

Step 15:

Answer 15

Inspects & palpates the trachea, assess if is midline

Question 16

Step 16:

Answer 16

Assesses ROM of head & neck by asking patient to touch chin to chest & to each shoulder, & then tip head back as far as possible. Note any pain or limitations.

Question 17

Step 17:

Answer 17

Inspects anterior and posterior thorax. Assesses skin color, symmetry, use of accessory muscles during respirations.

Question 18

Step 18:

Answer 18

Palpate for temperature, tenderness, and masses using the palmer surface of the hand.

Question 19

Step 19:

Answer 19

Auscultates the lungs both anterior and posterior thorax from apex to bases as the patient breathes slowly and deeply through the mouth (avoids breast tissue anteriorly & scapula posteriorly).

Question 20

Step 20:

Answer 20

Positions the patient supine position with the HOB elevated 30 to 45 degrees.

Question 21

Step 21:

Answer 21

Inspects the anterior chest for pulsations and heaves.

Question 22

Step 22:

Answer 22

Land-marks to locate the apical pulse at the 4th to 5th intercostal spaces and left mid-clavicular region. Identifies locations to best auscultate S1 and S2

Question 23

Step 23:

Answer 23

Palpate the apical impulse at the mitral area.

Question 24

Step 24:

Answer 24

Counts apical pulse for 1 minute and notes rate and rhythm

Question 25

Step 25:

Answer 25

Inspects the abdomen for shape or contour, pulsations, skin color, rashes, lesions, scars, or masses.

Question 26

Step 27:

Answer 26

Auscultates all four quadrants using the diaphragm of the stethoscope, starting in the RLQ.

Question 27

Step 26:

Answer 27

Palpates lightly in all four quadrants. Notes presence of tenderness. Palpates deeply in all four quadrants for masses.

Question 28

Step 28:

Answer 28

Inspects and palpates for distention of bladder (from symphysis pubis to umbilicus).

Question 29

Step 29

Answer 29

Assesses for the presence of urinary catheters, notes size of the catheter.

Question 30

Step 30:

Answer 30

Monitors urine output, noting color, clarity, and presence of foul odors.

Question 31

Step 31:

Answer 31

Inspects UPPER and LOWER extremities. Observes skin color, presence of lesions, or rashes.

Question 32

Step 32:

Answer 32

Assesses varicosities, hair and nail growth, muscle mass and presence of edema.

Question 33

Step 33:

Answer 33

Palpates for skin temperature, texture, and presence of masses.

Question 34

Step 34:

Answer 34

Inspects and palpates joints of UPPER extremities.
Assesses shoulder, elbow, wrist ROM– extension, flexion, abduction & adduction.
Assesses muscle strength of each.

Question 35

Step 35:

Answer 35

Inspects and palpates joints of LOWER extremities.
Assesses hip, knee and ankle ROM– extension, flexion, abduction & adduction.
Assesses muscle strength of each.

Question 36

Step 36:

Answer 36

Assess the color of the skin and capillary refill

Question 37

Step 37:

Answer 37

Palpates brachial and radial pulses, noting strength of each pulse.

Question 38

Step 38:

Answer 38

Palpates dorsalis pedis and posterior tibial pulses noting strength of each pulse.

Question 39

Step 39

Answer 39

Palpates the skin for temperature and presence of edema of UPPER and LOWER extremities – pitting and/or non-pitting.

Question 40

Step 40:

Answer 40

Assesses skin within each system. Inspects skin for color and presence of lesions or scars

Question 41

Step 41:

Answer 41

Turns patient and examines sacral/perineal area for redness, irritation or presence of decubitus ulcer if appropriate

Question 42

Step 42:

Answer 42

If appropriate-have the patient ambulate and note gait and spine