Head to toe assessment in nursing work.pptx

Poer point about head to toe examination which show steps and equipment used for assessment

1. Head to toe assessment Done by : - Nouf Nahari - Eman Arishi - Ohood Al- Balawi - Fatma Alsawqaee - Safa mashikhi - Ghamra alshiban - Ahlam Ibrahim Al- Asmary - Sharifah Alsallami Supervised by Dr. Maysa Mohd.

2. Introduction Assessment is a key component of nursing practice, required for planning and provision of patient and family- centered care. comprehensive head-to-toe assessment is done on patient admission. The head-to-toe assessment includes all the body systems, and the findings will inform the health care professional on the patient’s overall condition.

3. Purpose To understand the physical and mental well being of the patient. To detect diseases in early stages To determine the cause of disease To understand any changes in the condition of diseases, any improvement or deterioration.

4. Definition head-to-toe assessment is a procedure carried on a patient’s bod parts from the head throughout to the toe. It should be done each time you encounter a patient for the first time each shift (or visit, for home care, clinic or office nurses). An accurate assessment requires an organized and systematic approach using the techniques of inspection, palpation, percussion, and auscultation

5. Steps of assessment 1- Inspection: is Visual examination of a person . This is done in an orderly manner, focusing on one area of the body at a time 2- Palpation: Examination by touch . The nurses feels for texture, size, consistency, and location of body parts 3- Auscultation: Examination by listening for sounds produced within the body 4- Percussion: Examination of the body by tapping it with the fingers

6. Inspection It’s the use of vision to distinguish the normal from the abnormal findings. Body parts are inspected to identify color, shape, symmetry, movement, pulsation and texture.

7. Principals of inspection Availability of adequate light Position and expose body part to view all surfaces Inspect each area for size, shape, color, symmetry, Position and abnormalities. If possible compare each area inspected with the same area on the opposite side. Use additional light to inspect body cavities

8. Palpation It involves use of hands to touch body parts for data collection. The nurse uses fingertips and palms to determine the size, shape, and configuration of underlying body structure and pulsation of blood vessels. It help to detect the outline of organs such as thyroid, spleen or liver and mobility of masses. It detects body temperature, moisture, turgor, texture, tenderness, thickness, and distention.

9. Principles of palpation Principles of palpation Help client to relax and be comfortable because muscle tension impairs effective assessment. Advise client to take slow deep breaths during palpation Palpate tender areas last and note nonverbal signs of discomfort. Rub hands to warm them, have short fingernails and use gentle touch

10. Percussion It is the technique in which one or both hands are used to strike the body surface to produce a sound called percussion note that travels through body tissue. The character of the sound determines the location, size and density of underlying structure to verify abnormalities. An abnormal sound suggest a mass or substance like air, fluid in an organ or cavity.

11. Auscultation It involves listening to sounds and a stethoscope is mostly used. Various body systems like cardiovascular, respiratory and gastrointestinal have characterized sounds. Bowel, breath, heart and blood movement sounds are heard using the stethoscope. It is important to know the normal sound to distinguish from abnormal.

12. EQUIPMENT REQURIED FOR HEAD-TO-TOE EXAMINATION

13. Assessment procedure Vital signs : Temperature Pulse Respiration Blood pressure Height Weight General Appearance: Nourishment: well-nourished / undernourished Body build: thin / obese Health: healthy / unhealthy Activity: Active / dull(tired) This Photo by Unknown Author is licensed under CC BY-SA

14. Skin Conditions Color: Pallor/jaundice/cyanosis/flushing. etc. Texture: dryness/wrinkling/excessive moisture Temperature: Warm/cold/clammy Lesions: papules/wounds, etc. Head and Face Shape of the skull and fontanel Skull circumference Scalp : Cleanliness/ condition of the hair /dandruff/ infections like ringworm Face: Pale/ fatigue/ pain /fear / anxiety / enlargement of parotid glands, etc.

15. Eyes Eye brows: normal / absent Eye lashes: infection / sty Eye lids: Oedema / lesions Eye balls: Sunken / protruded Sclera: Jaundiced Pupils: Dilated/ constricted reaction to light Lens: Opaque / transparent Eye muscles: Strabismus[squint] Vision: Normal / myopia /hypermetropia. Ophthalmoscope

16. Ears External ear: discharge Tympanic membrane: Perforations / lesions / bulging Hearing : Hearing acuity Nose External nares: Crusts / discharges Nostrils : Inflammation of the mucus membrane / septal deviations Otoscope Nasal speculum

17. Mouth and Pharynx Lips: Redness / swelling / cyanosis Odor of the mouth: foul smelling Teeth: Discoloration and dental caries Mucus membrane & gums: Ulceration & bleeding / swelling / pus formation Tongue: pale / dry / lesions / tongue tie / sords Throat and pharynx : Enlarged tonsils / redness / pus Laryngoscope Tongue depressor

18. Neck Lymph nodes: enlarged / palpable Thyroid gland: enlarged Range of motion: Flexion / extension / rotation Chest Thorax: shape / symmetry of expansion / posture Breathe sounds: sigh / swish / rustle / wheezing / rales / pleural rub, etc. Heart : Size and location / cardiac murmurs

19. Abdomen Inspect abdomen for distension, asymmetry 2. Auscultate bowel sounds 3. Palpate four quadrants for pain and bladder/bowel distension (light palpation only) 4. Check urine output for frequency, colour , and odour . 5. Determine frequency and type of bowel movements .

20. Genital and Rectum Male Descent of the testes Presence of sexually transmitted diseases Hemorrhoids Enlargement of the prostate gland Female Vaginal discharges Presence of STD’s Hemorrhoids Pelvic masses Extremities Movement of joints / tremors / clumbing of fingers / Ankle edema / reflexes, etc. Protoscope

21. Nurse care plan The nursing should write every diagnosis write beside every diagnosis the appropriate planning Implementation Evaluation for every diagnosis

22. Evaluation Evaluation involves determining the effectiveness of the nursing care plan in achieving the desired outcomes and goals. Nurses assess the patient's response to the interventions and modify the plan as necessary. If the goals are met, the care plan may be revised to focus on the patient's ongoing health maintenance. If the goals are not achieved, the nurse reassesses the situation, identifies any barriers or challenges, and makes appropriate adjustments to the plan.

23. Documentation Accurate and thorough head-to-toe  assessment documentation  is essential. You should record your findings in a clear, concise, and organized manner. This includes noting vital signs, patient history, and the systematic assessment of each body system. Your head-to-toe assessment nursing notes  should be objective , focusing on what was observed and avoiding personal opinions or assumptions. Documenting any abnormalities, changes in condition, or concerns is important for effective communication among the healthcare team.

24. References 1. Ruth F. Craven Constance J. Hirnle , Fundamentals of Nursing, Human Health and Function , sixth edition(2009), Lippincott Williams & Wilkins. 2. Potter. Perry, Fundamentals of Nursing , 7 th edition(2009) Mosby Elsevier. 3. Barbara F. Weller, Nurses Dictionary for nurses and health care