Chapter 027

Head-to-Toe Examination and
Documentation
Chapter 27
Copyright © 2005, Mosby, Inc. All rights reserved. 1

Performing a Health Assessment
• Assessment begins with general survey
when first meeting client
– Observe client enter room, note gait, posture,
and ease of movement
– Shake hands, note eye contact and firmness
of hand grip
– Introduce self—data collection begins by
asking client reason for seeking care

• Assessment should begin with general
survey when first meeting client
– Note language spoken; gross hearing and
speech capability
– Observe for obvious vision difficulties/
blindness; difficulty standing, sitting, or rising

• Assessment should begin with general
survey when first meeting client
– Observe musculoskeletal difficulties
• General affect; interest, and involvement
• Dress and posture
• General mental alertness, orientation, and
integration of thought processes
• Obvious shortness of breath or posture that
facilitates breathing
• Obesity, emaciation, or malnourishment
• After initial observations—obtain history,
assess vital signs/vision, and prep for exam
• Instruct to empty bladder (collect specimen
if necessary)
• Remove clothing, put on gown, and sit on
exam table
• Conduct a focused assessment that
accommodates client’s needs

• Use following sequence only as guide. It
was developed to demonstrate how one
body system exam is integrated with other
body systems to permit a comprehensive
regional assessment
• Most important:
– Be organized
– Develop a routine (helps with consistency)

• Before beginning assessment, have
clear picture in mind of what you plan
to do and in what order
• Practice, practice, practice—learn to
become systematic and inclusive
• Imagine yourself as client—consider
how you would want nurse to be
prepared for your assessment
Guidelines for
Adult Examination Procedures
• Assessment data collected in general
survey during history
– Level of consciousness and mental status
– Mood or affect
– Personal hygiene
– Skin color
– Posture/position
– Mobility
– Ability to hear and speak
Guidelines for Adult Examination
• Assess vital signs and other baseline
measurements
– Temperature, radial pulse, respirations, and
blood pressure (both arms if indicated)
– Height, weight, and body mass index
– Visual acuity

• Examine hands
– When taking pulse and blood pressure,
inspect skin surface characteristics,
temperature, and moisture of hands
– Inspect for symmetry
– Inspect/palpate nails for shape, contour,
consistency, color, thickness, cleanliness, and
clubbing
– Test capillary refill
• Examine head and face
– Inspect skull for contour; hair for color and
distribution
• If indicated, palpate hair for texture; palpate scalp
– Palpate temporal pulses
– Inspect for facial features and symmetry
– Inspect bony structures of face for size,
symmetry, and intactness
– If indicated—ask client to
• Clench teeth
• Clench eyes tight, wrinkle forehead, smile, stick out
tongue, and puff out cheeks
• Examine head and face (cont’d)
– Inspect bony structures of face for size,
symmetry, and intactness
• Evaluate sensitivity of forehead, cheeks, and chin
to light touch
• Complete an assessment of cranial nerves
– Inspect skin for color and lesions
– If indicated
• Palpate—skin surfaces; facial bones; sinus regions
and transilluminate sinuses

– Examine eyes
• Near and peripheral vision
• Inspect eyebrows for hair distribution, underlying
skin, and symmetry
• Inspect eyelids and eyelashes for symmetry,
position, closure, blinking, and color
• Inspect conjunctiva and sclera for color and clarity;
inspect cornea for transparency
• If indicated, inspect anterior chamber
– Examine eyes
• Inspect symmetry of eye movement
– Test extraocular eye movement
– Perform cover-uncover test
• Inspect iris for shape and color
• Assess pupil—direct/consensual reaction, corneal
light reflex, accommodation
• Ophthalmic exam: inspect red reflex, disc cup
margins, vessels, retinal surface, macula

– Examine ears
• Inspect external ear/auditory canal
– Alignment, position, size, shape, symmetry,
skin color, intactness
– Discharge or lesions
• Palpate external ear/mastoid areas—tenderness,
edema, or nodules
– If indicated, perform whisper test to evaluate
gross hearing; perform Rinne’s and Weber’s
tests

– Examine ears
• Otoscopic examination [AP]: inspect
characteristics of external canal, cerumen,
eardrum (landmarks)
• Palpate lymph nodes of head

• Examine nose, mouth, and oropharynx
– Inspect
• Nasal structure and septum
• Nose for patency, symmetry, and discharge
– If indicated, evaluate sense of smell
• Lips, buccal mucosa, and gums for color,
symmetry, moisture, and texture
• Teeth for number, color, position, alignment,
hygiene, and condition
• Floor of mouth and hard and soft palates for color
and surface characteristics
• Examine nose, mouth, and oropharynx
(cont’d)
– Inspect
• Oropharynx for odor, anterior and posterior pillars,
uvula, tonsils, and posterior pharynx
– If indicated, grade tonsils
• Tongue for symmetry, movement, color, and surface
characteristics
– If indicated, palpate tongue and gums, evaluate
gag reflex, test temporomandibular joint for
movement
• Examine neck (cont’d)
– Observe symmetry and smoothness of neck,
trachea, and thyroid
• If indicated, palpate trachea and thyroid
– Inspect neck for range of motion
• If indicated, test range of motion of head and neck;
shrug shoulders against resistance

• Examine neck (cont’d)
– Palpate carotid pulses (one at a time)
• If indicated, auscultate for bruits
– Palpate lymph nodes of the neck
– Observe for jugular venous distention

• Examine upper extremities
– Inspect client’s arms for skin characteristics,
symmetry, and deformities
– Palpate
• Arms, elbows, and wrists for temperature,
tenderness, and deformities
• Brachial or radial pulse for presence and amplitude
• If indicated, palpate epitrochlear lymph nodes

• Examine upper extremities (cont’d)
– If indicated
• Test range of motion, muscle strength, and
sensation
• Test and bilaterally compare deep tendon reflexes
• Perform Phalen’s sign or Tinel’s sign for carpal
tunnel syndrome (AP)
• Test for rotator cuff damage (AP)

• Assess posterior chest (Nurse moves behind
client; client seated; gown to waist for men; gown
opened in the back for women)
– Observe posterior and lateral chest for
symmetry of shoulders, muscular
development, scapular placement, spine
alignment, and posture
– Inspect skin for color, intactness, lesions, and
scars
– Palpate vertebrae for alignment and
tenderness
• Assess posterior chest (cont’d)
– Observe respiratory movement for excursion,
symmetry, depth, and rhythm of respirations
– If indicated, palpate:
• Posterior chest and thoracic muscles for
tenderness, bulges, and symmetry
• Chest wall for thoracic expansion; posterior chest
wall for fremitus
• Down vertebral column for alignment and
tenderness
– Observe respiratory movement for excursion,
symmetry, depth, and rhythm of respirations
– If indicated
• Percuss (AP) posterior and lateral chest for
resonance
• Percuss and measure thorax for diaphragmatic
excursion
• Percuss costovertebral angle for tenderness

– Auscultate posterior/lateral chest walls for
breath sounds
• If adventitious sounds, assess for bronchophony,
egophony, and whispered pectoriloquy

• Assess anterior chest (Move to front of client;
client should lower gown to waist)
– Inspect for skin color, intactness, lesions, and
scars
– Observe respiratory movement for symmetry,
client’s ease with respirations, and posture
– Observe precordium for pulsations or heaving

• Assess anterior chest (cont’d)
– Palpate left chest wall to for point of maximum
impulse (PMI)
– If indicated
• Palpate chest wall for fremitus, as with posterior
chest
• Percuss anterior chest for resonance

• Assess anterior chest (cont’d)
– Auscultate anterior chest for breath sounds
– Auscultate heart for rate, rhythm, S1/S2
(location, intensity, frequency, timing, and
splitting), S3, S4, or murmurs

• Female breasts
– Inspect for size, symmetry, contour, surface
characteristics, and breast/nipple deviation
– Observe for symmetry of breast tissue during
movement: arms over head, behind head,
behind back; hand pushed together tightly,
client leaning forward

• Male breasts
– Inspect for size, symmetry, breast
enlargement, nipple discharge, or lesions
• All clients
– Palpate lymph nodes associated with
lymphatic drainage of breasts and axillae

• Assess anterior chest in recumbent
position
– Elevate head 45 degrees to inspect for jugular
vein pulsations
• If indicated, measure jugular venous pressure for
height above sternal angle
– Palpate anterior chest wall for thrills, heaves,
and pulsations
• If indicated, measure blood pressure with client
lying to compare with earlier reading
• Female breasts (Provide chest drape for females;
expose abdomen from pubis to epigastric region)
– Inspect for symmetry, contour, venous
pattern, skin color, areolar area (note size,
shape, and surface characteristics), and
nipples (note direction, size, shape, color,
surface characteristics, and discharge)
– Palpate breasts; note firmness, tissue
qualities, lumps, areas of thickness, or
tenderness; areolar and nipple area
– BSE
• Assess abdomen
– Observe
• Skin characteristics from pubis to midchest for
scars, lesions, vascularity, bulges, and navel
• For movement of abdomen, peristalsis, and
pulsations
– Inspect abdominal contour
– Auscultate abdomen (all quadrants) for bowel
sounds, bruits, and venous hums

• Assess abdomen (cont’d)
– Lightly palpate all quadrants for tenderness,
guarding, and masses
– If indicated
• Deeply palpate midline epigastric area for aortic
pulsation (AP)
• Percuss all quadrants and epigastric region for
tone (AP)
• Percuss upper/lower liver borders and estimate
liver span (AP)
• Percuss left midaxillary line for splenic dullness
(AP)
– If indicated, deeply palpate (AP)
• Right costal margin for liver border
• Left costal margin for splenic border
• Abdomen for right and left kidneys
– If indicated
• Test abdominal reflexes
• Assess abdomen for fluid

– Client raises head
• Evaluate flexion/strength of abdominal muscles
• Inspect for umbilical hernia
– If indicated, lightly palpate inguinal region for
lymph nodes, femoral pulses, and bulges that
may be associated with hernia

• Assess lower extremities (Client remains lying;
abdomen and chest should be draped)
– Inspect legs, ankles, and feet for skin
characteristics, vascular sufficiency, hair
distribution, and deformities
– Palpate lower legs and feet for temperature,
pulses, tenderness, and deformities
– If indicated
• Test range of motion, motor strength and
sensation of hips, legs, ankles, and feet

• Assess lower extremities (cont’d)
– If indicated (AP)
• Test for deep tendon reflexes
• Palpate hips for stability and tenderness
• Assess for knee effusion with bulge test or
ballottement
• Assess for knee stability with drawer test,
McMurray’s test, or Apley’s test
• Assess for hip flexion contracture with Thomas’s
test
• Assess nerve root compression with straight-leg
raises
• Assess remaining neurologic system
– Observe client moving from lying to sitting
position; note use of muscles, ease of
movement, and coordination
– Assess gait: observe and palpate spine for
alignment as client stands and bends forward
to touch toes
– If indicated, evaluate hyperextension,
lateral bending, and rotation of upper
trunk
• Assess remaining neurologic system (cont’d)
• Test sensory function by using light and deep (dull
and sharp) sensation
• Bilaterally test and compare vibratory sensation
• Test proprioception by moving toe up and down
• Test two-point discrimination
• Test stereognosis and graphesthesia

(cont’d)
• Test fine motor functioning and coordination of
upper extremities by instructing client to perform at
least two of the following:
– Alternating pronation and supination of forearm
– Touching nose with alternating index fingers
– Rapidly alternating finger movements to thumb
– Rapidly moving index finger between nose and
examiner’s finger
(cont’d)
– If indicated
• Test fine motor functioning/coordination of lower
extremities—have client run heel down tibia of
opposite leg
• Evaluate Babinski’s sign and ankle clonus tests
(AP)
• Test for meningeal signs with Kernig’s and
Brudzinski’s signs (AP)
(cont’d)
– If indicated, assess cerebellar and motor
functions (use at least two of the following)
• Romberg’s test (eyes closed)
• Walking straight heel-to-toe formation
• Standing on one foot/then other (eyes closed)
• Hopping in place on one foot/then other
• Knee bends

• Assess genitalia, pelvic region, and rectum

(Male client is lying, adequately draped)
– Inspect pubic hair for distribution and general
characteristics
– Inspect and palpate penis for color, tenderness,
discharge, and general characteristics
– Inspect
• Scrotum for texture and general characteristics
• Sacrococcygeal and perianal areas and anus for
surface characteristics

• Assess genitalia, pelvic region, and
rectum (cont’d)
(Position client lying on left side with right hip and knee
flexed)
– Palpate anal canal and rectum for surface
characteristics with lubricated gloved finger
• Note characteristics of stool when gloved finger
removed

rectum (cont’d)
– If indicated, palpate anterior rectal surface for
prostate gland size, contour, consistency,
mobility, and tenderness (AP)
– With client standing, inspect inguinal canal for
bulges

rectum (cont’d)
– Palpate testes, epididymides, and vas
deferens for location, consistency,
tenderness, and nodules
• Transilluminate scrotum for fluid and masses
• Palpate inguinal canal for hernias

rectum (con’t’d)
(Female client should be lying in lithotomy position;
examiner should don gloves)
– Inspect the public hair for distribution
– Inspect and palpate the labia majora, labia
minora, clitoris, urethral meatus, vaginal
introitus, perineum, and anus for surface
characteristics
rectum (cont’d)
– If indicated
• Palpate the Skene’s and Bartholin’s glands for
surface characteristics
• Inspect and palpate muscle tone for vaginal wall
tone, rectal muscle, and urinary incontinence
• If indicated, insert vaginal speculum and inspect
surface characteristics of vagina and cervix (AP)
• If indicated, collect Papanicolaou (Pap) smear and
culture specimen [AP]
rectum
– If indicated [AP]
• Perform bimanual palpation to assess form, size,
and characteristics of vagina, cervix, uterus, and
adnexa
• Perform vaginal-rectal examination to assess
rectovaginal septum and pouch, surface
characteristics, and broad ligament tenderness

rectum (cont’d)
– If indicated
• Perform rectal examination to assess anal
sphincter tone and surface characteristics; note
characteristics of stool when lubricated gloved
finger removed
– Client resumes seated position; client should
have gown on and be draped across lap

Infant and Pediatric Examination
• Procedure depends on age and
cooperation of child
– Procedures that child perceives as painful
should be performed at end of exam
– When child is school age should be able to
participate in a cooperative manner
– Younger child presents a greater challenge
– Format changes from adult to pediatric exam

Health Assessment Documentation
• Information collected during the health
assessment must be organized and
documented
• Components of the documentation
– Subjective data (history)
– Objective data (health assessment)
– Risk profile
– Problem list/nursing diagnoses

Health Assessment Documentation
• Document what is observed, heard,
percussed, or palpated
• Nurse avoids using vague and non-
descriptive terms such as normal,
negative, good, or poor.
• Always be specific and descriptive

Documentation Format:
Subjective Database (History)
• Biographic data
• Chief complaint for seeking health care
• History or present illness or health status
– Current health promotion activities
– Client’s perceived level of health
– Current medications/allergies

• Past health history
– Childhood illnesses
– Surgeries
– Hospitalizations
– Accidents or injuries
– Chronic diseases
– Last examinations
– Obstetric history
• Family history
• Personal and psychosocial history
– Family and social relationships
– Diet/nutrition
– Functional ability; mental health
– Personal habits
– Health promotion activities
– Environmental hazards
Documentation Format: Subjective
Database (History)
• Review of systems
– General symptoms
– Integumentary (skin, hair, nails)
– Head and neck
– Breasts
– Respiratory system/chest
– Cardiovascular system

• Review of systems
– Gastrointestinal system
– Reproductive system
– Musculoskeletal system
– Neurologic system

Documentation Format: Objective
Database (Physical Examination)
• General survey
• Integumentary system
• Head and neck
• Nose, nasopharynx, sinuses
• Mouth and oropharynx
• Ears and auditory system
• Eyes and visual system

• Lungs and respiratory system
• Heart and peripheral vascular system
• Breasts and axilla
• Abdomen and gastrointestinal system
• Musculoskeletal system
• Neurologic system
• Anus, rectum, and prostate
• Female genitalia and reproductive system

• Male genitalia

Documentation Format
• Risk profile
– Potential problems from client’s history and
health assessment that indicate risk to overall
health status
– After determining risk factors, discuss how
may be modified (if possible)
• Not all risk factors are modifiable
– History and health assessment—excellent
opportunity to discuss health promotion

• Nursing diagnoses and collaborative
problems list
– Selected based on synthesis of client data
(objective/objective)
– Cluster data to identify nursing diagnoses or
collaborative problems
– List and assign priority—decide which are
within scope of practice to complete and
which must be referred to other health care
providers
• Nursing diagnoses and collaborative
problems list
– Always document accurately and completely
subjective and objective finding
– Your record will be basis for subsequent care
delivered to client

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Head-to-Toe Examination and

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• Assess genitalia, pelvic region, and rectum

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• Female genitalia and reproductive system

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