Health and Physical Assessment of the Adult Client - Nursing
A head-to-toe assessment is a comprehensive physical examination critical for nurses to assess patients. The review includes all the body systems, and the findings will inform the healthcare professional of the patient's overall conditi...
Test bank for clinical nursing skills and techniques 10th edition by Anne Griffin Perry, Patricia A. Potter Chapter 1-43 A+ Complete Guide Latest 2025
Test Bank For Fundamentals of Nursing 9th Edition By Patricia A. Potter, Anne G. Perry, Patricia A. Stockert, Amy Hall
ATI MATERNAL NEWBORN PROCTORED EXAM 2024 WITH CORRECT ANSWERS AND RATIONALES
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HEAD-TO-TOE ASSESSMENT
Pre-Procedure Guide ● Gather all necessary PT info from charge nurse report, or
during end-of-shift report.
● Gather all necessary supplies
● Perform hand hygiene.
DURING PROCEDURE GUIDE
General Survey **Knock on the door, open the door, and provide privacy (either
close the door or close the curtain)**
General appearance check: - Introduce yourself, title, and purpose of visit.
● Gender ● Perform safety check (Bed brakes, side rails, clutter, potential
● Signs of distress
● Age and developmental
safety hazards, etc.)
level ● Evaluate ABCs:
● Hygiene, grooming ○ Is the client’s airway compromised?
● Posture, gait (coordinated ○ Assess rate and ease of breathing.
or uncoordinated, posture: ○ Circulation
pain and mood)
● Distribution of body fat ■ Assess for the presence of a radial pulse.
and muscle, ■ Assess skin colour, moisture, and
● Striking features ■ temperature for signs of decreased tissue
● Language, expression perfusion (pale, dusky, cool, or clammy
● Culture skin).
● Odor
● LOO → is the PT A&O to DATE, PLACE, NAME
● Pain ax: LPQRST
○ Ask if PT is experiencing any pain.
○ Ask PT to rate pain on a 1-10 scale.
○ Ask PT to describe the pain:
■ shooting, burning, aching, radiating, pins
and needles?
○ When it started, and what triggered it.
● Ask PT if they require mobility aids, hearing aids, dentures,
etc.
● Ask PT what types of ADLs they can perform independently,
which ones they require assistance.
1
, HEAD-TO-TOE ASSESSMENT
Vital Signs → NOTE: The position of the PT and site of where v/s taken must be
indicated in the documentation. → Laying vs. Sitting, Right vs.
Left arm, etc.
Temperature → Oral, Tympanic, or rectal; 36.5-37.5 degrees
- It’s normal for older adults to have lower body temps than
younger PTs.
Heart Rate → 60-100/min
- Description: strong, regular, weak, absent, etc.
RR → 12-20/min
- Note for signs of accessory muscle use
- Any audible sounds on expiration and/or inspiration?
BP → 120/80; sphygmomanometer used on upper L/R arm
O2 Saturation → 95-100%; Oximeter
INSPECTION → Inspecting the hair: fine thick and smooth hair , no rash, no
bleeding noted, no lice noted, no grey hair. Also the check
condition and distribution of hair and integrity of the scalp.
a) Terminal hair - long coarse hair, thick, visible
b) Vellus hair - small, soft hair, covering soles/palms
c) Thin, brittle hair (concerning) - screen PT w/ thyroid
stimulating hormone test.
Inspecting the head:
- lesions, abnormalities, bleeding, scratches and assess if the
head is positioned at the midline to the trunk and is upright.
- *If head is tilted to one side - possible indication of unilateral
hearing or visual loss*. Also consider past traumas and scars,
history of headaches and their duration and the PT’s
occupational history. Examine PT’s size, shape and contour of
skull.
PALPATION → Palpating the head:
- round head ,no depression, nodules or masses when palpated (
do this by gently rotating the fingertips down to the midline of
the scalp and along the sides of the head)
- Normal: symmetrical and no depressions, nodules, masses
*If pt has had head trauma, local skull deformities may be
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