Head-To-Toe Assessment A. Head (Skull, Scalp, Hair)

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1. Observe the size, shape and contour of the skull.
2. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
3. Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so. (wear gloves if necessary)
4. Observe and feel the hair condition.

Normal Findings:

Skull
· Generally round, with prominences in the frontal and occipital area. (Normocephalic).
· No tenderness noted upon palpation.

Scalp
· Lighter in color than the complexion.
· Can be moist or oily.
· No scars noted.
· Free from lice, nits and dandruff.
· No lesions should be noted.
· No tenderness nor masses on palpation.

Hair
· Can be black, brown or burgundy depending on the race.
· Evenly distributed covers the whole scalp (No evidences of Alopecia)
· Maybe thick or thin, coarse or smooth.
· Neither brittle nor dry.

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• Head-To-Toe Assessment (M. Nose and Paranasal Sinuses) The external portion of the nose is inspected for the following: 1.     Placement and symmetry. 2.    Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing) 3.    Flaring of alaenasi 4.    Discharge The external nares are palpated for: 1.    Displacement of bone and cartilage. 2.    For tenderness and masses The internal nares are inspected by heperextending
• Head-To-Toe Assessment (D. Eye lids and Lacrimal Apparatus) 1. Inspect the eyelids for position and symmetry. 2. Palpate the eyelids for the lacrimal glands. a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim. b. Inquire for any pain or tenderness. 3.
• Head-To-Toe Assessment (Q. Breast) Inspection of the Breast There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position. The client is seated with her arms on her side. The client is seated with her arms abducted over the head. The
• Head-To-Toe Assessment (R. Abdomen) In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles. Inspection of the abdomen Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus). Contour
• Head-To-Toe Assessment (L. Ears) 1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color. 2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process. 3. Inspect the auditory meatus or the