Head to Toe Assessment

Vital Signs:

  • Any signs of distress indicating a patient emergency
  • Patient's level of consciousness, speech, orientation

 

Eyes:

  • Pupil size response to light
  • Extracurricular eye movements
  • Accommodation

 

Mouth:

  • Skin color around lips and tip of nose (checking for circumoral cyanosis)
  • Mucous membranes for moisture (area between gums and cheek will stay moist even with a mouth breather unless patient is dehydrated)

 

Neck for neck vein distention


Anterior chest

Vesicular (Listen to the sound)
low, breezy soft sounds heard over the periphery of the lung fields

Bronchial (Listen to the sound)
Course, loud sound heard over the trachea

Bronchovesicular
Equal inspiration and expiration, medium quality, heard over the mainstem bronchi


3-D Display Demo


Posterior Chest


Heart Sounds: Listen to Basic Heart Sounds

  Aortic Pulmonic Tricuspid Mitral
Location 2nd intercostal space at the right sternal border 2nd intercostal space at the left sternal border 4th or 5th intercostal space at the left lower sternal border 5th intercostal space near the left midclavicular line
Loudest sound S2 S2 S1 S1

Abdomen

Observe the abdomen for symmetry, contour, movement
Listen in each of the four quadrants for bowel tones.
Lightly palpate if indicated (tenderness, bladder distention) 

Steps to auscultate bowel sounds:

  1. Place diaphragm of stethoscope LIGHTLY over each four quadrants room should be quiet.
  2. Listen for repeated gurgling or bubbling sounds in EACH quadrant (minimum of once in 5 to 20 seconds).  If patient has an N/G suction you may need to clamp while listening.
  3. Describe sounds as normal (active), hyperactive, hypoactive, or absent.  (Listen 5 minutes over each quadrant before deciding bowel sounds are absent.)
  4. Nurse Alert:  If aortic bruit is auscultated, suggesting presence of an aneurysm, stop assessment and notify physician immediately -  check patient's H & P too.
    • Normal bowel sounds occur irregularly every 5 to 15 seconds.  Common for bowel  sounds to be hypoactive postoperatively for 24 hours or more (esp. following abdominal surgery).
    • Absence of sounds cessation of gastric motility
    • Hyperactive (not related to hunger or recent meal) diarrhea or early intestinal obstruction.
    • Hypoactive or absent paralytic ileus or peritonitis

Upper Extremities: CMS checks

Circulation: Capillary refill, radial pulses
Motion/Sensation:

  • Hand grasps
  • Push/pull
  • Straight arm raise

 

Lower Extremities: CMS checks

Circulation: Capillary refill, posterior tibial and dorsalis pedis pulses
Motion/Sensation:

  • Push/pull
  • Leg raise

 

In listening to breath sounds, while listening to either the anterior or posterior chest, be sure to auscultate the right middle lobe on the right lateral side of the chest.