Summary
Highlights
Begin the head-to-toe assessment by checking the patient's alertness and orientation (AO x 4) to person, place, time, and situation. This involves asking their name, current location, date/year, and reason for hospitalization.
Next, assess the eyes for symmetry, pupil size, shape, and reactivity to light and accommodation (PERRLA). Check the sclera and conjunctiva for abnormalities. Palpate the sinuses, inspect the nares for patency, and examine the mouth for abnormalities of lips, oral mucosa, tongue, gums, and teeth.
Move on to the neck by palpating the lymph nodes and thyroid gland for nodules. Assess tracheal symmetry, ability to swallow, airway patency, and range of motion. Inspect for jugular venous distension (JVD) and auscultate carotid arteries for bruits using the bell of the stethoscope while the patient holds their breath.
Perform a chest assessment by auscultating heart sounds in the five areas (aortic, pulmonic, Erb's point, tricuspid, mitral) using the diaphragm and checking for murmurs with the bell. Assess the apical pulse and note any abnormalities.
For lung assessment, observe chest expansion, respiratory rate, and check for difficulty breathing or coughing. Auscultate lung sounds in all fields, comparing left to right, listening for decreased or adventitious breath sounds. Key landmarks include above the clavicle (apex), second and fourth intercostal spaces anteriorly, and the sixth intercostal space mid-axillary (bases). Posteriorly, listen above the scapula (apex) and between C7-T3 (midline) and T3-T10 (bases).
For abdominal assessment, remember to look, listen, then feel. First, inspect for abnormalities or distension. Then, auscultate bowel sounds in all four quadrants for at least one minute each, noting normal, hyperactive, hypoactive, or absent sounds (listen for 3-5 minutes to confirm absence). Finally, palpate gently in a clockwise motion, using the palmar aspect of your fingers, for abnormalities like muscle guarding, rigidity, or superficial masses. Inquire about bowel habits and last bowel movement.
Examine extremities for deformity, skin abnormalities, symmetry, and edema. Palpate for tenderness, soft tissue swelling, and joint effusions. Assess vasculature by checking capillary refill and palpating pulses in all locations on both arms, legs, and feet. Test range of motion for each joint, muscle strength and tone (scale 0-5), and observe gait. For diabetics, thoroughly examine toes for ulcerations or cuts and document all findings.