Head to Toe Assessment: The Quick Version

A full physical head to toe assessment is completed upon admission and at the start of
each shift. The focus is on vital assessment parameters, tracking changes from shift to
shift and should take no more than 5 minutes to complete. Several activities in the
assessment can be completed at the same time. Usually, it is individualized to fit the
client’s condition, diagnosis and level of acuity.

Step 1:
Evaluate the client’s level of consciousness, eye contact and responsiveness, color and
texture of the skin, any IVs, dressings or tubes visible. Ask appropriate questions to
determine orientation to time and place. Establish the nurse-client relationship at this
time.

Step 2:
Assess vital signs. While taking the client’s pulse, feel the skin temperature and moisture.
Check bilateral radial pulses. Observe for edema in face or neck. Individualize the
assessment: for example, with a neurological condition, check pupils.

Step 3:
Remove client’s gown or raise the gown. Use the stethoscope to listen to heart sounds,
apical pulse and breath sounds bilaterally. Observe breathing patterns, symmetry of chest
movement, shape of chest, and depth of respirations. Check for skin turgor.

Step 4:
Auscultate abdomen for bowel sounds. Use palpation and percussion techniques only if
appropriate to diagnosis. Palpate bladder if necessary (based on output). If catheter is in
place, observe urinary output for color, odor, consistency and amount.

Step 5:
Assess lower extremities for warmth, color, moisture, and presence of pedal and popliteal
pulses, muscle tone and sensation. Assess for pedal edema or general edema in the lower
extremities. Check traction or casted areas for skin breakdown, alignment and placement.

Step 6:
Have client turn onto side or sit at edge of bed. Assess posterior lung fields and symmetry
of chest movement with inspiration. Assess skin for pressure areas, particularly coccyx
and heels when client returns to side-lying position. Evaluate client’s ability to move in
bed.
Head to Toe Assessment: The Long Version
Neurological Assessment:
The neurological assessment starts with the initial contact with the client. Evaluation of
verbal responses, movement, and sensation is carried out throughout the examination. In
addition, functions of the cerebrum, cerebellum, cranial nerves, spinal cord, and
peripheral nerves are assessed. The level of consciousness is the most sensitive and
reliable index of cerebral function.
Subjective Questions:
11. Evaluate verbal responses to questions around time, person, place and purpose.
22. Ask questions around sensations like pain, itching, burning, tingling or numbness.
33. Ensure that client’s mood is appropriate to situation, is able to follow commands,
and long/short term memories are intact.

Objective Assessment:
Normal Abnormal

11. Level of Consciousness: 1• Drowsy

0 • Awake 2• Difficult to awaken
1 • Alert 3• Unable to give date, month,
2 • Appropriate Mood place
3 • Responds to verbal commands 4• Irritable
4 • Answers questions appropriately 5• Memory deficit
5 • Speaks clearly 6• Difficulty finding words
6 • Orientated to time, person, place and 7• Does not recognize family
purpose
7 • Recent and remote memory intact

12. Motor Responses: 1• Eyes closed

0 • Eyes open 2• Does not follow directions
0 • Follow commands to
stick out tongue, squeeze
fingers, move extremities
1 • Responds to painful
stimuli
13. Pupil Assessment:
0 • Size of pupil: 1.5-6
mm
1 • Shape of pupils:
round and mid-position
1• Does not localize or withdraw from pain
2• Assumes decorticate posturing (legs extended, feet
extended with plantar flexion, arms internally rotated
and flexed to chest) May be due to lesion of
corticospinal tract
3• Assumes decerebrate posturing (arms stiffly
extended and hands turned outward and flexed, legs
extended with plantar flexion) due to lesion in midbrain
4• Assumes flaccid posturing/no motor response; may
be due to extreme injury to motor area of brain
5• Involuntary movements: tremors, spasms, seizures
1• Sluggish: early warning of deteriorating condition
2• Unilateral dilation: sign of 3rd cranial nerve
involvement
3• Bilateral dilation: sign of upper brain stem damage
4• Unilateral dilation: sign of increased intercranial
pressure or compression of 3rd cranial nerve
5• Mid-position and fixed: sign of midbrain
involvement
0 • Equality of Pupil: Equal 1• Pinpoint and fixed: opiate effect
1 • Reaction to Light: (using penlight in 2• Unequal: sign that sympathetic and
darkened room, open eye being tested, cover parasympathetic nervous systems are
opposite eye): Pupil constricts promptly not synchronized
2 • Light Reflex: (both eyes open, shine
light in one eye only, observe opposite eye): both
pupils constrict
3 • Accommodation: (ability of lens to
adjust to objects at varying distances): Lens can
adjust

Head and Neck Assessment:

The names and the regions of the head come from the bones that form the skull. Knowing
the names of the bones and regions of the skull can assist in describing the location of
physical findings.
The brain is made up of three sections: the brain stem, cerebrum, and the cerebellum.
There are 12 cranial nerves and 31 pairs of spinal nerves with dorsal and ventral roots.
The brain stem is divided into four sections: A.) The diencephalons which includes the
thalamus (that relays sensory impulses to the cortex) and the hypothalamus (which
regulates the autonomic nervous system, stress response, sleep, appetite, body
temperature, water balance and emotions), B.) The midbrain (responsible for motor
coordination and eye movements, C.) The pons (controlling involuntary respiration) and
D.) Medulla (contains cardiac, respiratory, vomiting and vasomotor centers).

The cerebral hemispheres have and outer layer of gray matter, called the cerebral cortex.
The two hemispheres are divided into four major lobes. The frontal lobe controls
emotions, judgments, and motor function. The parietal lobe integrates general sensations;
interprets pain, touch and temperature sensations. The temporal lobe contains the
auditory center and sensory speech center. The occipital lobe controls the visual area. The
cerebellum coordinates muscle movement, posture, equilibrium, and muscle tone.
Cranial Nerves and Their Function
Cranial Function Testing Cranial Nerves
Nerve
 I Olfactory Sensory nerve Recognizes odor in
each nostril separately
II Optic Sensory nerve: conducts sensory Demonstrates visual
information from the retina acuity

IV Motor nerve controls the superior oblique Moves eyes to the

Trochlear eye muscle right, up and down then
left
V Mixed nerve with three sensory branches Demonstrates normal
Trigeminal and one motor branch: the ophthalmic facial sensations
branch supplies the corneal reflex

VI Abducens Motor nerve: controls the lateral rectus Moves eye

muscle of the eye laterally

VII Facial Mixed nerve: anterior tongue receives Elevates eyebrows,

sensory supply, motor supply to glands puffs cheeks,
of nose and palate, supplies muscles of recognizes tastes
expression and closes eyes

VIII Acoustic Sensory nerve: hearing and semicircular Hears whispers

canals with each ear
separately
IX Mixed nerve: motor to parotid gland and Gag reflex at back
Glossopharyngeal sensory to posterior taste buds of tongue

X Vagus Mixed nerve: motor branches to Same as IX

pharyngeal, laryngeal, thorax and
abdomen. Sensory to ear, thoracic and
abdomen

XI Accessory Motor nerve: innervates the trapezuius Shrugs shoulders

muscles
XII Hypoglossal Motor nerve: controls tongue muscles Sticks tongue out
in midline

Subjective Questions:
11. Inquire about their eyes and visual abilities? Do they require any aids to see?
22. Inquire about their ears and earring abilities? Do they require any aids to hear?
Objective Assessment:
Normal
Eye Assessment:
1• Note visual acuity: observe ADL’s—
should perform adequately
1• Note any lesions: No lesions should
be noted
2• Equality of eyelid movement:
should be equal in movement
3• Discharge: No discharge
4• Pupil size and reaction: should be
the same
Ear Assessment:
1• Ask if they hear normal sounds as
you make them: should have no
difficulties
2• Note any external lesions: No
lesions should be noted
3• Discharge: should have no
discharge from ear
Nose Assessment:
1• Structural changes: able to breathe
regularly with mouth closed
2• Discharge: should only have
minimal discharge
Abnormal
1• Age related macular degeneration, near
and farsightedness
1• Small plaques can indicate lipid disorders
2• Paralytic drooping of the upper lid
3• Thick discharges can be conjunctivitis
4• May indicate neurological trauma or deficit
1• Deafness, ringing of ears or buzzing could be
caused by ototoxic drugs
2• Battle’s sign: may be sign of basilar skull
fracture
3• Redness, swelling and pain can be infection
4• Cerebrospinal fluid discharge indicates head
injury
1• Obstruction to breathing can be due to
deviated septum, swelling of tissues or
excessive secretions
2• Cerebral spinal fluid indicates trauma
Mouth and Lip Assessment:
1• Note any lesions: should have no 1• Can indicate dehydration, fissures, pressure
external lesions sores
2• Note any internal lesions: 2• White patches can indicate

1should have no internal lesions 1fungal infection

(Candidiasis)

Neck Assessment:
1• Note any lesions or swelling: can have occasional small, 1• Enlarged, tender,
mobile non-tender lymph nodes immobile nodes

Chest Assessment:
Assessment of the chest includes lungs, breasts and heart. External aspects should be
observed including symmetrical movement, posture, shape of breasts and axilla area
along with internal components of lungs and heart.
The lungs extend from 2 to 4 cm above the third clavicle to the eighth rib at the midline.
Posteriorly the lungs extend from the third spinous process to the tenth process and on
deep inspiration to the twelfth process. Ensure when auscultating breath sounds to
alternate from left field to right field as you work your way down. Examination of the
chest usually proceeds from posterior to anterior with the client in the upright position.
Ask the client to breath a little deeper than usual through their mouth rather than nose
since this can produce extra sounds that mask true lung sounds.
The heart is located directly behind the sternum, with the left ventricle projecting into the
left chest. The action of the heart should be assessed both proximally and distally.
Proximal assessment involves evaluating heart sounds, heart rate, and rhythm to obtain
information about the mechanical activity of the heart. Distal assessment involves
evaluating the peripheral pulses to obtain information about the effectiveness of the
heart’s pumping action. One method to assess heart sounds is to start at the aortic area,
move slowly across to the pulmonic area, down to the tricuspid area and over to the
mitral area. The most important thing to remember is to use a consistent method to
compare the different sounds.
Examples of heart and lung sounds can be heard at:
http://solutions.3m.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-
lung-sounds/

Breast assessment should include observing for lumps, drainage, dimpling of breast tissue
and asymmetry. Any changes that the client indicates should also be noted.
Subjective Questions:
11. Ask questions around breathing, exercise and tolerance.
 22. Ask if they have any problems with their circulatory system.
33. Inquire about medications currently in use.
Objective Assessment:
Normal
Respiratory Assessment:
1• General shape:
straight spine, relaxed
breathing, level
shoulders, ribs that slant
downwards
2• Note respiratory Rate:
12-20 resp/min
3• Auscultation: No
extra sounds heard—
symmetrical areas should
be the same in quality
and intensity
Heart Assessment:
Auscultation
1• Mitral Valve sound:
heard best over left, fifth
intercostal
Abnormal
1• Breathes sitting forward (emphysema), uses accessory
muscles (respiratory distress), curvature of spine, horizontal
ribs (COPD), bulging interspaces during exhalation
2• Increased rate may be due to fever, injury, surgery or
trauma to chest wall
3• Crackles (due to sudden opening of closed airways),
wheezes (air passing through narrowed airways), rhonchi
(low-pitched rumbling heard on inspiration/expiration-may be
cleared with coughing) Absent Breath sounds—may indicate
atelectasis, pneumothorax or pleural effusion Faint Breath
sounds—may indicate hypoventilation, early atelectasis and
COPD
1• Heart sounds not heard in the area (e.g., with left
ventricular
1space and medial to midclavicular line:
S1 heart sound (combination of mitral
and tricuspid closer)
2• Tricuspid valve sound: heard best at
intercostals space, left sternal border: S1
heart sound
3• Aortic Valve sounds: heard best at
second intercostals space, right sternal
border: S2 heart sound (combination of
aortic and pulmonic closure)
4• Pulmonic Valve sounds: heard best at
second intercostals space, left sternal
border
5• Heart Murmurs: heard between heart
sounds—produced by atypical flow of
blood through the heart: faint sound can
often be heard in children and young
adults
1hypertrophy, mitral sound moves laterally)
2• Sounds altered with aortic stenosis (thrill)
and hypertension (accentuated sound)
3• Accentuated with pulmonary hypertension
4• S3: Ventricular Gallop: heard best just
after S2 at the apex or lower—almost always
signifies heart failure in client over 40
5• S4: Atrial Gallop: heard just before S1, at
the apex, occurs when blood flow from atrial
contraction meets increased resistance in
ventricle—Normal finding in elderly with
hypertension
6• Can be faint or loud: Present in older
clients with heart disease
1• Peripheral pulses: radial, brachial, femoral, popiteal, dorsalis pedis, 1• Difficult
posterior tibial: Easily palpated, strong bilaterally, posterior tibial weaker to palpate
than femoral 2• Unequal
pulses
3• Weak
pulse
4• Absent
pulses

The Gastrointestinal and Genitourinary Systems:

The abdomen extends from the diaphragm to the pelvis and contains two body systems
the gastrointestinal and the genitourinary systems. The gastrointestinal system begins at
the mouth and consists of the esophagus, stomach, small and large intestines and the
associated organs including the liver, pancreas and spleen. This system has two major
functions of digestion and distribution of nutrients and elimination of wastes.
The urinary tract consists of the kidneys, ureters, bladder and the urethra. The urinary
tract should be assessed frequently and accurately because of changes in urine production
reflect changes in other body systems. The easiest way to assess the urinary tract system
is to note the quantity and quality of the urinary output.
External male genitalia include the penis, the scrotum and testicles. External female
genitalia include the vulva, the urethral orifice and the vagina.
Subjective Questions:
11. Ask if they have any abdominal pain or discomfort. Noting the location, intensity
and if it is constant can help to determine which systems are affected.
22. Establish what their bowel routine is. Information on frequency, constipation,
diarrhea and use of laxatives or elimination aids are required.
33. Nutritional issues such as appetite, food intake, swallowing or chewing
difficulties along with weight loss or gain should be noted.
44. Assess for the presence of urinary urgency, nocturia, frequency, incontinence or
burning while voiding. The color and volume of urine should be assessed.
15. If pertinent ask if they experience genital itching, lesions, discharge, painful or
swollen tissue and for women review their menstrual cycle.

Objective Assessment: Abdominal assessment is best done while patient is lying flat in
bed. Inspection and palpation of genitalia can be done while assisting patient with
personal care or toileting.
 Normal
Abdomen:
Inspection:
Client lying flat in bed
1• Contour of Abdomen: abdomen flat
from chest to pubis
2• Skin Appearance: no change in skin
color around umbilicus
3• Circumference: place tap around
largest circumference, draw two lines
(top/bottom): No increase in abdominal
circumference
Auscultation:
Bowel sounds: place stethoscope firmly
on right lower quadrant and count
sounds for 1 minute—rotate to all
quadrants to assess
1• Bowel sounds gurgle about 5-30 per
minute
2• More sounds can be noted before and
after eating
Abnormal
1• Concave contour: due to inadequate
nutritional intake or inadequate food
absorption
2• Distended: caused by gas and fluid
accumulation due to decreased peristalsis,
hemorrhage or intestinal leakage post trauma
(surgery or auto accident)
3• Scars, stretch marks, dilated veins,
presence of hernia
4• Abdominal circumferences increasing
steadily within 1-2 hours may indicate
hemorrhage or ascites
5• Increased sounds: due to blood in GI tract,
diarrhea, or partial obstruction
6• Hypoactive sounds may be quiet and
infrequent due to
1• Will be absent initially post surgery—
with general anesthesia sounds will return
in 1-2 days and abdominal surgery they
will return within 3-5 days
Palpation:
Client lying flat in bed and mouth
breathing, place your hand flat on
abdomen with four fingers together and
depress 5 cm, palpate all quadrants to
assess organs contained within
1• Soft pliant musculature when relaxed
2• Coughing does not produce pain in
abdomen
3• No bulges or masses felt
Urinary Tract:
1• Visually inspect the external urethra:
orifice is pink and moist, clear with
minimal discharge
2• Urine output: assess quantity, color,
odor, specific gravity and pH of urine.
Output should be 1200-1500ml/24 hours or
30-50 ml/hour—should equal oral and IV
intake
3• Clear, yellow-amber color
1peritonitis or paralytic ileus
2• Absent sounds can indicate complete
obstruction or systemic illness
3• Rigid muscles can indicate inflammation
or infection
4• Pain with cough can indicate peritoneal
inflammation
5• Masses can be felt with colon disease,
vascular aneurysm, distended bladder or
cancer
1• Burning or pain may indicate infection
2• Increased output can indicate increased
intake, diuresis, diabetes mellitus or
antidiuretic hormone response. Frequent
small amounts of output can indicate
retention or infection
3• Decreased output may indicate
dehydration, renal failure, or excess ADH
response
4• Cloudy can indicate infection, dark
amber can indicate
1• Slight odor
2• Specific Gravity: 1.003-1.030
3• Blood: check for blood using hemastix:
no blood should be present
4• Bladder Distention: Not normally
palpated
5• Pain: Assess for pain—should be no
pain
Genital Assessment:
Male: Visually inspect the skin for lesions,
discharge and cleanliness
1• Clean, no odor, no discharge, no lesions
2• Noting groin area: no bulges in groin
3• Testicles: gently palpate each testicle
for size, shape and consistency: two
testicles in scrotum, no nodules, no
swelling or tenderness
1dehydration, dark amber to green can
indicate hepatitis or jaundice
2• Foul-smelling may indicate infection, or
drug ingestion
3• Specific gravity >1.030 can indicate
dehydration, constant specific gravity of
1.010 regardless of intake indicates renal
failure
4• Blood can indicate infection
5• Distended bladder accompanied by
discomfort and urge to void indicates
retention
6• Severe pain in the flank region can
indicate kidney infection or stones
1• Unclean, odor, lesions/discharge can
indicate venereal disease or cancer
2• Bulging on straining can indicate hernias
3• Mass in scrotum: indicates possible
hernia, hydrocele, tumor or cyst
Female: Visually inspect the skin for
lesions, discharge and cleanliness
1• Clean, no odor, no discharge, no
lesions, no signs of sexual abuse
2• Assess for lesions/discharge:
minimal, clear discharge, menstrual
flow, no lesions, no pruritus
1• Pain indicates inflammatory disease, unclean,
can have musty odor (with bacterial infection),
bruises, welts or swelling can be noted with
abuse
2• Thick, yellow, white, or green discharge can
indicate trichomoniasis, curdy discharge can
indicate candidiasis, lesions can indicate
syphilis/herpes or venereal wart

Anus and Rectum: While examining

the perineum the perianal and
sacrococcygeal areas can also be
inspected.
1• Smooth uninterrupted, intact skin
2• More pigmented than surrounding
skin
3• Moist and hairless
1• Lumps, rashes, inflammation, lesions can
indicate infection
2• Internal hemorrhoids can be seen by asking
patient to bear down
3• Bleeding can indicate tumor or infection
4• Rectal pain can indicate abscess or infection

Skin Assessment:
Initial skin assessment and grading is completed on all patients at the time of admission
using the Braden Scale for Predicting Pressure Sore Risk (PHC-EL029). Skin assessment
can be incorporated into other parts of the physical assessment, but it is important to
ensure that all areas of the body are checked. Pressure ulcers occur predominantly over
bony prominences, and excess moisture often causes breakdown in the buttock, inner
thigh, and groin areas. Patients with any of the following could be at risk for skin
breakdown: decreased sensory perception, increased moisture on the skin, decreased
activity, decreased mobility and

decreased nutritional intake. In addition the presence of friction or shearing on the skin, a
history of pressure ulcers and any disease process that impairs blood flow/perfusion also
increases patient’s risk for developing a pressure sore.
Subjective Questions:
11. Does this patient have a history of pressure ulcers, nutritional impairment,
diabetes or heart disease?
22. Is the patient mobile and active? Is there increased pressure or shearing that can
occur due to lack of mobility?
33. Is increased moisture noted on the skin (ie: incontinence, diaphoresis, weeping
edematous legs)?

Objective Assessment:
Normal
General Inspection:
1• Smooth, intact skin with
normal firmness or tensile
strength
2• Uniform warmth
3• Uniform color
Abnormal
1• Varicose veins (indicates circulation difficulties)
2• Abrasions, rashes, dermatitis, blisters, hematomas,
skin tears, lacerations, ulcers or wounds
3• Areas of hardness (indurations)
4• Areas of skin that are warmer or hot to the touch-can
indicate infection
5• Areas of the skin that are cooler than surrounding
areas (i.e. lower legs and feet can indicate circulation
difficulties)
6• Skin that is discolored can be sign of damage from
pressure—appears reddened/bruised
1• Uniform hydration 1• In dark-skinned people, redness is often not
noticeable, but can feel hot or warm to touch
2• Areas of diffuse redness may indicate cellulites
3• Area of blackened tissue—necrosis
4• Moist or wet skin—especially in skin folds and
groin area
5• Dry, flaky skin

Area Specific: Legs and Feet

1• Smooth skin, hair growth in
areas with follicles, healthy toe
nails with regular thickness
2• Normal uniform skin color to
lower legs
1• Shiny, taunt skin with no hair growth and
thickened nail beds is sign of Arterial disease
2• Hemosiderin staining (brownish areas of staining
noted to lower legs sign of venous stasis disease
3• Atrophy blanche (whitish areas on the skin) is
caused by flattened blood vessels and are found
around old or current leg ulcer sites

Mental Health Assessment:

The mental assessment is done throughout the physical assessment. It is not generally
considered a separate entity. Mood, memory orientation and thought processes can be
evaluated while obtaining the health history. The purpose of the mental status assessment
is to evaluate the state of psychologic functioning and to monitor safety needs of the
client. It is not designed to make a diagnosis but

rather it should provide data that contributes to the total picture of the client at the time of
the assessment.
Assessment goals should include: collecting data to aid in establishing the cause,
diagnosis, and prognosis, to evaluate the state of psychologic functioning, to determine
client’s ability to cope with the present situation, to assess the need and availability of
support systems and to determine the guidelines of the treatment plan.
Initial factors that the nurse must consider in completing a mental status assessment
include correctly identifying the client, the reason for admission, history of any previous
mental illness, present complaint, any personal history that is relevant (such as living
arrangements, history of alcoholism, domestic violence) and support systems available.
Subjective Questions:
11. What their admission is for and how long they are expected to be in hospital?
22. Any history of previous mental illness?
33. Any personal history that is relevant such as history of substance abuse or
domestic violence?
44. What support systems do they currently have available to them and do they have
pressing stressors that would worsen by staying in hospital (for example: financial
concerns or children to care for)?

Objective Assessment:
Normal
General Appearance, Manner and Attitude:
Physical Appearance: general characteristics, energy
level
Note grooming, mode of dress, and personal
hygiene: appropriate to grooming and dress to
situation, age and social circumstance, clean
Abnormal
1• Inappropriate appearance, high
or low extremes of energy
2• Poor grooming, inappropriate
or bizarre dress or combination of
clothes, unclean

Note speed, pace, quantity and volume of speech:

Moderate speed, volume and quality of speech 1• Accelerated or retarded speech
Relevance, content, organization of responses and high quality
2• Inappropriate responses,
unorganized pattern of speech,
out of context replies
Expressive Aspects of Behavior:
General motor activity: calm, ordered movement 1• Overactive, agitated or
appropriate to situation impulsive
Purposeful movements and gestures: reasonable 2• Repetitious activities
movements, appropriate gestures 3• Disordered attention,
Level of Consciousness: alert, attentive, and distracted, cloudy consciousness,
responsive, aware of time, place and person delirious, stuporous

Thought Processes and Perception:

Assess coherency, logic, and relevance of thought 1• Disorientated in time, place,
processes by asking questions by asking about person
personal history: clear, understandable responses to 2• Disorientated thought forms
questions and attentiveness 3• Withdrawn, absent
Assess reality orientation to time, place and person mindedness, dogmatic or
awareness: orderly progression of thoughts, preaching
awareness of time, place and person 4• Disordered progression of
thought: looseness,
circumstantial, incoherent,
irrelevant conversation
5• Delusions of grandeur, no
awareness of day, time or place
Mood or Affect:
Assess variability in mood by observing
behavior and asking “How are you feeling
right now?”: appropriate, even mood
without high variations high to low
Assess depth and significance of mood if
questioning depression: may be sad or
grieving but mood does not persist
indefinitely
Memory:
Assess past and present memory and
retention: alert, accurate responses, past
and present memory appropriate
Assess recall with questions about birth
date, age or place of birth: good recall of
immediate and past events
Judgment:
Assess judgment and decision making
ability: ability to make accurate decisions,
realistic interpretations of events
Lifestyle Patterns:
Identify addictive patterns and effect on
individual’s overall health: Normal amount
of alcohol ingested, smoking habits,
prescriptive medications, adequate food
intake
Coping Devices:
Identify defense-coping mechanisms and
their effect on the individual: conscious
coping mechanisms used
1• Mood swings, euphoria, elation
depression, withdrawn
2• Flat or dampened responses,
inappropriate responses or ambivalence
1• Excessive loss of memory, amnesia,
belief in events that never occurred
2• Poor recall of immediate or past events
1• Poor judgment, poor decision making
ability, poor choice, inappropriate
interpretation of events or situations
1• High quantity of alcohol taken
frequently, heavy smoker, addicted to
illegal drugs, habitual user of over the
counter medications, anorexic or
overindulgence of food
1• Unconscious mechanisms used
frequently: repression, regression,
projection,
appropriately such as rationalization, suppression,
sublimation or displacement 1reaction formation,
insulation or denial

For video taped examples of assessments go on-line to:

http://www.mc.maricopa.edu/dept/d31/nur/learning_objects/_assessment/PhysicalAssess
ment.html
Nursing Diagnoses:
Once information is gathered from the head to toe assessment and the various data
sources then it can be combined to generate central nursing diagnoses. As the database
evolves, patterns of health problems emerge and alterations from normal health states are
identified. Nursing diagnoses provides a vocabulary that is used to describe specific
nursing practices, research and education. It provides a method to synthesize and
communicate nurses’ observations and judgments to all members of the health care team.
Surveillance Diagnoses:
Surveillance Diagnoses (Meyer/Lavin) is a new term identified to explain and incorporate
the extra work that nurses participate in. These diagnoses are based upon the vigilant
work performed by the nurse. Vigilance is based on nursing knowledge and is the
prerequisite for informed nursing action. It is the backdrop against which professional
nursing activities are performed. It is the “watch-ful-ness” that is always part of the
nurse’s thinking process as activities are completed.
In Meyer and Lavin’s (2005) groundbreaking article, surveillance diagnoses are separated
from central nursing diagnoses based upon the accountability of the nurse and the health
care team.
Central nursing diagnoses such as “ineffective airway clearance” or “self-care deficit” are
considered central nursing diagnoses because they reflect the independent nursing
practice. For surveillance diagnosis, the nurse is accountable for professional vigilance
and the recognition of the problem but is not solely accountable for the interventions or
outcomes.

Central and surveillance diagnoses often exist in tandem. For example, if your client is
and older adult with poor eyesight and is receiving medication for hypertension then the
surveillance diagnosis is “risk for orthostasis”. Nursing intervention includes monitoring
blood pressure changes lying, sitting and standing. Information gained would allow the
nurse to work with the team (pharmacist/physician) to alter medications if the problem
became severe. This client also has a central diagnosis of “risk for falls related to
orthostasis”. This calls for independent nursing action to treat with teaching, safety
measures and more frequent observation. In the end, the nurse shares responsibility for
the management or prevention of the orthostasis, but is independently accountable for
preventing falls in this patient.
Conclusion:
Head to toe physical assessment is one through way in which to gather information in
order to systematically assess, plan, intervene and evaluate the care of our clients. By
using the consistent terminology of central and surveillance diagnoses helps nurses to
describe to others the important work that we do.
Test Your Knowledge:
11. What sources would you utilize to gather information about your patient’s
condition?
1A. The patient.
2B. Clinical values and tests.
3C. Tests, medical history, physical assessment and other health professionals.
4D. All of the above.
22. What is the 5th vital sign?
1A. Glasgow’s Coma scale.
2B. Pain Assessment.
3C. Peripheral pulses.
4D. Mental Health Assessment.
33. When is a physical assessment performed?
1A. Upon admission.
2B. Upon admission and start of each shift.
3C. Upon admission, start of each shift and as needed.
4D. As needed.
44. Which cranial nerve recognizes taste and moves eyebrows?
1A. Trigeminal nerve.
2B. Trochlear nerve.
3C. Facial nerve.
4D. Vagus nerve.
55. What is the most reliable indicator of cerebral function?
1A. Level of Consciousness.
2B. Pupil response.
3C. Motor response.

16. Faint breath sounds may indicate…

1A. Normal breath sounds over lower lung fields.
2B. Atelectasis.
3C. Pleural Effusion
4D. B and C.
27. Which statement is true? Atrial Gallop (S4 heart sound) is a(n)…
1A. Abnormal finding in elderly with hypertension.
2B. Normal finding in elderly with hypertension.
3C. Dangerous finding in elderly.
4D. A and C.
38. What is the correct order of assessment for the abdomen?
1A. Inspection, Palpation and Auscultation.
2B. Auscultation, Palpation, Inspection.
3C. Inspection, Auscultation, Palpation.
4D. Palpation, Auscultation, Inspection.
49. What is one of the most important pieces of information needed when performing
a skin assessment?
1A. What their weight is.
 2B. If they have varicose veins.
3C. If they have had a history of pressure sores.
510. If your client is overactive, agitated or impulsive they show impairments in….
1A. Expressive aspects of behavior.
2B. Judgment.
3C. Coping Devices
4D. Mood or Affect.

Test Answers:
11. D
22. B
33. C
44. A
55. A
66. D
77. B
88. C
99. C
1010. A

Glossary:
11. Subjective Data: Information that can only be verified by that person. Examples
would include pain, itching and worry.
22. Objective Data: Information that is detectable by an observer or can be tested by
an accepted standard. Examples of this would include a blood pressure,
discoloration of the skin or witnessing crying.
33. Central Diagnosis: A nursing diagnosis as a clinical judgment about individual,
family and community responses to actual or potential health problems or life
processes. Must be one that the nurse can select a nursing interventions and be
held accountable for the outcome. They are termed ‘central’ because they reflect
independent nursing practice. Examples include: ‘ineffective airway clearance’,
‘activity intolerance’, ‘self-care deficit’ and ‘risk for falls’.
44. Surveillance Diagnosis: Is a clinical judgment about individual, family and
community response to actual or potential health problems or life processes.
Nurse is accountable for professional vigilance and the recognition (or diagnosis)
of the problem, but is not solely accountable for the interventions or outcomes.
Nurse participates inter-professionally, in the ongoing management of the
problem. Examples include: ‘risk for hypoglycemia’, ‘risk for hemorrhage’, ‘risk
for increased intracranial pressure’, ‘risk for deep vein thrombosis’.