Head-To-Toe Physical Assessment of an Adult Patient - Essay Example

The whole purpose of conducting a head-to-toe examination is to test the functionality of all the body parts under examination.

During my stay at a local hospital, I had the chance to conduct a head-to-toe assessment of an adult patient. In this essay I am going to describe the approach I used for the examination, the techniques, instruments, and, in the end, I will give documentation of my findings. For confidentiality purposes, I will name my patient Laura (not her real name).

When she checks in at the hospital, Laura complains about general body fatigue, lack of appetite, and insomnia. There seems to be a genuine reason for these symptoms, and a physical examination is needed to determine the cause and possible treatment. As Rosdahl & Kowalski (2007) indicate, a head-to-toe assessment is important during admission since the data collected helps provide treatment and nursing care for the patient. I, therefore, decide to conduct a head-to-toe assessment of Laura and hand the results over to the physician.

First I ask Laura to loosen her clothes and then I proceed to assess her head. Here, I look at Laura’s hair color and texture. I also look for any bald spots or uneven hair distribution. Next, I check the face for any deformities and then go on to palpate the head for any tenderness or deformities. I then check her eyes. Here, I check whether there is any redness in the eyes and I use a penlight to examine pupil size, shape, movement, and reaction to light. The penlight is also very useful in checking the iris and cornea. I use an acuity chart to test Laura’s vision in relation to distance. As for the outer eye, I check the eyelids and eyelashes.

 The next procedure involves the dental region, where I palpate the maxillae and mandibles for any swellings and lesions. Inside the mouth, I check for any unusual odors, loose teeth, discolored teeth, and dentures. I then ask Laura to stick out her tongue as I check its color, texture, and other oral structures. As for the nose, I block one of Laura’s nostrils as she breathes through the other and then alternates the procedure. I also use a nasal speculum to inspect the inside of Laura’s nostrils. Finally, I palpate the nose to check for any bump or tenderness. Next, I observe the ears, using the penlight for any abnormal fluids and wax. I palpate the ear to check for any lesions and swelling. I also check the positioning of the ears in relation to the face.

After that, I look for any deformities and bruises of the neck. I palpate the neck for any tender spots as I also observe the jugular veins.  I also palpate the thyroid gland for any abnormal enlargements and tenderness. As Laura moves her head, I look for any enlarged lymph nodes.

For the chest examination, I ask Laura to sit at the edge of the examining table. I first observe the anterior chest to check the shoulder level, the symmetry of the breasts, and rib margins. I also observe the respiratory movement, that is, the rising and falling of the chest wall with each inhalation and exhalation. I observe the posterior chest for the same respiratory movements and the positioning of the spinal code. After this, I palpate Laura’s anterior chest to look for any abnormal formations. The next step is to listen to the respiratory system, in particular to any sounds coming from the lungs or the heart. I place a stethoscope at Laura’s anterior chest and then ask her to take a deliberate deep breath through the mouth.

A breast examination is next. I ask Laura to place her hands at the sides of her body on the bed, as I examine the nipples, the area around them, and the whole breast. I look at the relativity in the shape and dimension of the breasts. I then ask Laura to lift up her hands to see whether the breasts move in a similar fashion. As for the abdomen, I look at the location of the umbilicus, the symmetry of the abdomen, as well as its shape. The texture of the skin is also very important. I also check for any abnormal tensions in the abdomen. I palpate all four quadrants, the area around the liver, spleen, and kidney. I then use the stethoscope to auscultate the abdomen to check for any bowel sounds.

As for the arms, I observe the skin for uniformity in color and texture. I also check the elasticity of the skin and also check muscle mass. I test Laura’s muscle strength by asking her to push against the resistance of my hands. I inspect Laura’s elbow, wrist, and finger joints for lesions and swellings. I also inspect the fingernails for color and shape. Palpation of the hands enables me to record the skin temperature with the use of a thermometer. As regards her legs, I palpate the skin for pulse and temperature and then inspect them for varicosities and color. I also look at the toenails for color and growth. I check for any signs of edema. I then ask Laura to lift her legs in a straight line as I check for any problems with her vertebral disk.