Question

write a head-to-toe assessment of a healthy patient admitted for an appendectomy that is scheduled in an hour

Answer 1

A head-to-toe assessment refers to a physical examination or health assessment, and it becomes one of the many important components of understanding a patient’s needs and problems.

Physical head to toe assessment of patient admitted for apendectomy.

• Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit.
• Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed.
• Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 second
• Head: The head of the client is rounded; normocephalic and symmetrical.
• Skull: There are no nodules or masses and depressions when palpated.
• Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.

• Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows.
• Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
• Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute.
• Eyes
• The Bulbar conjunctiva appeared transparent with few capillaries evident.
• The sclera appeared white.
• The palpebral conjunctiva appeared shiny, smooth and pink.
• There is no edema or tearing of the lacrimal gland.
• Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched.
• The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose.
• When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead.
• When testing for the Extraocular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.
• The client was able to read the newsprint held at a distance of 14 inches.
• Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears.
• Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions
• Mouth:
  • The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his lips when asked to whistle.
  • Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums
  • The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.
  • The tongue of the patient is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin whitish coating.
  • The smooth palates are light pink and smooth while the hard palate has a more irregular texture.
  • The uvula of the patient is positioned in the midline of the soft palate.
• Neck:
  • The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort.
  • The lymph nodes of the patient are not palpable.
  • The trachea is placed in the midline of the neck.
  • The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.
  • Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and effortless respirations.
  • The spine is vertically aligned. The right and left shoulders and hips are of the same height.
  • Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts.
  • Abdomen: The abdomen of the patient has an unblemished skin and is uniform in color. The abdomen has a symmetric contour. There were symmetric movements caused associated with client’s respiration.
    • The jugular veins are not visible.
    • When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds
    • Patient complains of sharp pain in right illiac fossa
• The extremities are symmetrical in size and length.
• Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth, coordinated movements.
• Bones: There were no presence of bone deformities, tenderness and swelling.
• Joints: There were no swelling, tenderness and joints move smoothly