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Head to Toe Assessment

BODY PART TECHNIQUE USED FINDINGS INTERPRETATION

◊ HEAD
Skull ◊ palpation ◊ proportional to ◊ Normal
the size of the body,
round, with
prominences in the
frontal area
anteriorly & the
occipital area
posteriorly,
symmetrical in all
planes, gently
curved

Scalp/ Hair ◊ inspection ◊ scalp is white, ◊ Normal


◊ palpation clean, free from
masses, lumps, nits,
dandruff & lesions,
with no areas of
tenderness upon
palpation; hair is
black, evenly
distributed & covers
the whole scalp,
thick & shiny

Face ◊ inspection ◊ oblong shaped, ◊ Normal


symmetrical, smooth
& no involuntary
muscle movements

Eyes/ Vision ◊ inspection ◊ eyes are parallel ◊ Normal


◊ palpation & evenly placed,
symmetrical, non-
protruding, with
scant amount of
secretions, both
eyes black & clear;
sclera is white &
clear; eyebrows
are black,
symmetrical, thick,
can raise both
symmetrically &
without difficulty,
evenly distributed &
parallel with each
other; eyelashes
are evenly
distributed & turned
outward; upper
eyelids cover a
small portion of the
iris, cornea & the
sclera when the
eyes are open, when
the eyes are closed
the lids meet
completely,
symmetrical & the
color is the same as
the surrounding
skin; lid margins
are clear, without
scaling or
secretions; lower
palpebral
conjunctiva are
shiny, moist,
transparent &
salmon pink in color;
iris are proportional
to the size of the
eye, round &
symmetrical; pupils
are from pinpoint to
almost the size of
the iris, round,
symmetrical,
constricts with
increasing light &
accommodation;
able to move eyes in
full range of
direction

Ears/ Hearing ◊ inspection ◊ ears are parallel, ◊ Normal


◊ palpation symmetrical,
proportional to the
size of the head,
bean-shaped, helix
is in line with the
outer canthus of the
eye, skin is the
same color as the
surrounding area &
clean; ear canal is
pinkish, clean, with
scant amount of
cerumen & a few
cilia; able to hear
whisper spoken 2
feet away; 2
piercing are found in
left ear and 1
piercing in right ear

Nose ◊ inspection ◊ nose is in midline, ◊ Normal


◊ palpation symmetrical, patent;
internal nares are
clean, dark pink with
few cilia

Mouth/ Lips ◊ inspection ◊ lips are pinkish, ◊ Normal


◊ palpation symmetrical, lip
margin is well-
defined, smooth &
moist; gums are
pinkish, smooth,
moist, no swelling,
no retraction, no
discharge; 32 teeth
are present, aligned,
with no dental
caries; tongue is
pinkish, slightly
rough on top,
smooth along the
lateral margins,
moist, shiny & freely
movable;
cheeks are pinkish,
moist & smooth;
frenulum is in
midline, straight &
thin; soft palate is
pinkish, smooth &
moist; hard palate
is slightly pinkish;
uvula is at the
center, symmetrical
& freely movable

◊ NECK ◊ inspection ◊ proportional to ◊ Normal


◊ palpation the size of the body
& head, symmetrical
& straight, no
palpable lumps,
masses or areas of
tenderness

◊ THORAX & ◊ inspection ◊ chest contour is ◊ Normal


LUNGS ◊ palpation symmetrical, spine is
◊ percussion straight, no lumps,
◊ auscultation no masses, no
tender areas, with
clear breath sounds

◊ HEART ◊ inspection ◊ no abnormal ◊ Normal


◊ palpation pulsations,
◊ percussion pulsations are
◊ auscultation palpable & visible in
apical area

◊ BREAST ◊ inspection ◊ symmetrical, ◊ Normal


◊ palpation pinkish nipples, no
cracks & discharges,
uniform in skin
color, smooth &
intact, no lumps,
masses &
tenderness

◊ ABDOMEN ◊ inspection ◊ abdominal skin ◊ Normal


◊ auscultation is unblemished, no
◊ percussion scars, color is
◊ palpation uniform with the
body color,
abdomen is
rounded with
symmetric
movements caused
by respiration;
umbilicus is
concave

◊ UPPER ◊ inspection ◊ symmetrical, with ◊ Normal


EXTREMITIES ◊ palpation visible veins, fine
hair evenly
distributed, warm,
dry & elastic upon
palpation, with area
of tenderness on the
left arm; palms are
pinkish, warm, soft
& elastic; nails are
transparent, smooth
& convex with light
pink nail beds &
white translucent
tips; 5 fingers in
each hand; both
shoulders, arms,
elbows, hands &
wrists can be
moved in different
range of motion with
relative ease; c
marks of petechial
rashes

◊ LOWER ◊ inspection ◊ skin is smooth, ◊ Normal


EXTREMITIES ◊ palpation fine hair is evenly
distributed, absence
of varicose veins,
muscles
symmetrical, length
symmetrical, 5 toes
in each foot, sole &
dorsal surface is
smooth with pink
nail beds & white
translucent tips;
both legs, knees,
ankles, & toes can
be moved in
different range of
motion with relative
ease; scar on both
patellar; c non
pitting bipedal
edema