HEAD TOE EXAMINATION :
General Examination or Head toe Examination :
The examination is carried
in an orderly manner focusing upon one area of the body at a time .the observation of the client
starts as the client walks into the examination room, e.g., a limp may be noted as the
client walks in. the following observations are made.
General Appearance :
Nourishment
: Well nourished or under nourished
Body build:
Thin or obese
Health
: Healthy or unhealthy
Activity :
Active or dull (tired)
Mental Status
Consciousness:
Conscious, unconscious, delirious, talking, incoherently
Look:
Anxious or worried, depressed etc.
Posture:
Body curves :
lordosis, Kyphosis, scoliosis.
Movement : Any
limp.
Height and weight
:
Skin condition:
Color: Pallor,
jaundice ,cyanosis, Flushing etc.,
Texture : Dryness
,flaking ,wrinkling or Excessive moisture.
Temperature: Warm
,cold and clammy.
Lesions: macules
,papules, vesicles wounds etc.,
Head and Face
Shape of the skull and
fontanelles (noted in the newborns ).
Skull circumference.
Scalp: Cleanliness,
condition of the hair ,dandruff , pediculi, infection like ringworm.
Face : Pale, Flushed, puffiness, Fatigue, pain,fear
,anxiety , enlargement of parotid glands etc.
Eyes:
Eyebrows: Normal
or absent
Eye Lashes: Infection
,sty.
Eyelids : Oedema,
lesions, ectropion (eversion), entropion(inversion).
Eyeballs: Sunken
or protruded.
Conjunctiva : Pale,
red ,purulent
Sclera : Jaundice.
Cornea and iris
: Irregularities and abrasions.
Pupils: Delated, constricted , reaction to light.
Lens : Opaque
or transparent
Fundus : Congestion
, hemorrhagic Spots.
Eye muscles: Strabismus(squint).
Vision: Normal,
Myopia (Short sight ,Hyperopia (long sight ).
Ears:
External ear : Discharges, Cerumen Obstructing the
ear passage.
Tympanic Membrane
: perforations, lesions, bulging.
Hearing : Haring acuity.
Nose:
External nares : Crusts ordischarge
Nostrils : inflammation of the mucus membrane, septal deviations.
Mouth and Pharynx :
Lips:
Redness, swelling , crusts, cyanosis, angular stomatitis.
Odor of the mouth: Foul smelling
Teeth:
Discoloration and dental caries.
Mucus membrane & gums : Ulceration
and bleeding, swelling ,pus formation.
Tongue : pale
,dry, lesions sords, furrows, tongue tie etc.,
Throat & pharynx : Enlarged tonsils, redness and pus.
Neck :
Lymph nodes : Enlarge,
palpable
Thyroid gland : Enlarged.
Range of motion: Flexion ,extension and rotation.
Chest :
Thorax: Shape,
Symmetry of exemption ,posture.
Breath sounds : Sigh, swish ,rustle, Wheezing crepitation , pleural rub etc.
Heart:
Size and location ,cardiac murmurs.
Breast :
Enlarged lymph nodes.
Abdomen:
Observation : Skin rashes, scar hernia ,ascites distension,
Pregnancy etc.
Auscultation : Bowel
Sounds, foetal heart sounds
Palpation : Liver
margin , palpable spleen , tenderness at the area of appendix inguinal hernia
Percussion : Presence
of gas, fluid or masses
Extremities :
Movement of joints, tremors,
clubbing of fingers ,ankle oedema, varicose veins, reflexes etc.
Back :
Spina bifida, curves,
Genitals and Rectum
:
Inguinal lymph glands-enlarged, Pslpsble.
Patency of urinary meatus and rectum (in infants).
Descent of the testes (in
infants).
Vaginal discharges.
Presence of sexually
transmitted diseases.
Hemorrhoids.
Enlargement of the prostate
gland pelvic masses
Neurologic
Test :
Coordination tests.
Reflexes.
Equilibrium test . Test for
sensations.
PHYSIOLOGICAL ASSESSMENT :
(a VITAL SIGNS
, NORMAL ,ABNORMAL CHARACTERISTICS, FACTORS INFLUENCING THE VARIATIONS:
VITAL SIGNS:
The temperature, pulse,
respiration and blood pressure are called vital signs or cardinal signs” in a
normal healthy individual they remain
constant . They are called ‘ vital signs because :
1. These findings are governed by vital organs and often
reveal even the slightest deviation from
the normal body functions.
2. The changes in the condition of the patient,
improvement or regression may be
detected by the observation of the thee signs.
3. Significant variation in these findings may indicate
problem relating to insufficient consumption of oxygen, blood depletion ,
electrolyte imbalance , bacterial invasion and other problems.
4. Through these signs, specific information may be
obtained what will help in the diagnosis of disease, the result of treatment , medications and nursing care.
5. Even the patient’s emotional state may also cause
significant variation in these symptoms.
·
The normal body temperature is 98.6 F or 37 C in
adults .
·
The normal pulse
is 72 beats/ minute in adults.
·
The normal
respiration is 16/ minute in adults.
·
The normal blood
pressure is 120/80 mm of hg in adults.
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