Assignment Help

Purpose:

The purpose of this assignment is to assess your ability to conduct a systematic and comprehensive head-to-toe physical assessment. This will help reinforce critical thinking, clinical reasoning, and documentation skills essential for nursing practice. By completing this assignment, you will demonstrate proficiency in assessing various body systems, identifying normal and abnormal findings, and effectively documenting your observations.

Head-to-Toe Physical Assessment Write-Up Template

Section

Details to Include

General Survey

– Appearance: Describe the patient’s general appearance (e.g., hygiene, posture, grooming). – Behavior: Note demeanor, mood, and level of consciousness. – Vital Signs: Include temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

Integumentary

– Inspection: Describe skin color, texture, moisture, and any lesions, scars, or rashes. – Palpation: Note skin temperature, turgor, and edema (if present).

HEENT

– Head: Describe scalp, hair, and any abnormalities (e.g., lumps, tenderness). – Eyes: Note symmetry, conjunctiva, sclera, visual acuity, and pupil response (PERRLA). – Ears: Assess external ears, hearing, and any discharge. – Nose: Inspect nasal mucosa, septum, and patency of nostrils. – Throat: Examine oral mucosa, teeth, gums, and throat for abnormalities.

Neck

– Inspection: Assess for symmetry, swelling, or masses. – Palpation: Check for thyroid enlargement or tenderness. – Range of Motion (ROM): Evaluate neck mobility.

Lymph Nodes

– Palpation: Note size, tenderness, and mobility of cervical, axillary, and inguinal lymph nodes.

Thorax and Lungs

– Inspection: Observe chest symmetry, shape, and effort of breathing. – Auscultation: Document breath sounds (e.g., clear, wheezes, crackles).

Cardiovascular

– Inspection: Note any visible pulsations or jugular vein distention (JVD). – Palpation: Assess peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial). – Auscultation: Listen to heart sounds (S1, S2, murmurs).

Abdomen

– Inspection: Observe shape, contour, and skin condition. – Auscultation: Note bowel sounds in all four quadrants. – Palpation: Describe any tenderness, masses, or organomegaly.

Genitourinary

– Inspection and Palpation: Note bladder distension, tenderness, or abnormalities. – Subjective Data: Include patient-reported urinary frequency, urgency, or incontinence.

Extremities & Peripheral Vascular

– Inspection: Evaluate for symmetry, swelling, or deformities. – Palpation: Assess temperature, capillary refill, and pulses. – ROM and Strength: Test joint range of motion and muscle strength.

Neurological

– Mental Status: Assess level of consciousness, orientation (person, place, time), and cognition. – Cranial Nerves: Evaluate cranial nerve function as applicable. – Motor Function: Test strength, tone, and coordination. – Sensory Function: Check for sensation to touch, pain, or temperature. – Reflexes: Document deep tendon reflexes.