Assessment in nursing

Nursing assessment is a critical phase in the caring process. It is frequently referred to as the nursing process's foundation. A fruitful evaluation can lead to a speedy patient recovery, but a weak or incorrect assent can lead to wasteful and incorrect nursing diagnoses and plans, as well as a mistaken intervention and evaluation. Head to toe examinations are typically time-consuming, lasting up to three hours depending on the patient's demands. A stethoscope, observational skills, a reflex hammer, and a penlight are all necessary tools for performing an examination. At first, a nurse may not be able to play a head to toe assessment rapidly, but the more nurses practice medical procedures, the more experience they gains and the faster they became in performing a head to toe assessment. While assessing any client, a nurse should watch after some common characteristics such as hair color, and facial expressions. In short, the overall appearance of a patient forms the basis of assessment. After assessing the patient with the general appearance, the nurse should then embark to a head-to-toe system assessment using four main procedures; which are inspection, palpation, percussion, and auscultation (Mahaffey & Robertson, 2017). This sequence is used in most assessments except for abdominal evaluations that need auscultation before palpation and thumping. Percussion and Palpation are done with hands to evaluate irregularities of sound, chest expansion, distended organs and displaced organs. A stethoscope to listen to bowel sounds helps in auscultation, breath and heat beats (Haugh, 2015).

Equipment used for Assessment

Haugh (2015), points out that the primary tool used for a head to toe assessment is a stethoscope. However, when using a stethoscope, a nurse should recall that any movement of the tubing or chest piece caused by clothing or hands could lead to excess more noise than average and if a nurse is not careful, this can lead to a wrong diagnosis. The diaphragm piece must be placed resolutely on the skin; it improves sounds (these include breath noises, bowel movements and heartbeats). The bell piece can also be sited very casually to collect low-pitched sounds, such as vascular sounds and irregular sounds from the heart. In cases where the bell is firmly set, it expands the skin and acts as a diaphragm. Other equipment includes the reflex harmer, penlight, turning folk, ophthalmoscope, and otoscope.

Health History

According to Wilkinson, Treas, Barnet, & Smith (2016), a head to toe assessment begins with a nurse interviewing the patient about their health history (using open-ended question). These issues help the nurse to collect data about the patient’s past health disorders, present problems, and contemporary needs. Such evidence can only be acquired through the objective (such as observable traits) and subjective (revealed by the client) data collection techniques. Data collected from such sources during the assessment could help a lot in classifying nursing analyses and instituting a personalized care design. A whole wellbeing history includes biographic data such as age, education level, living set ups. Principal complaint; these are the disorders that brought the client to healthcare/ the motive for the visit and the latest changes. Present health (Lindo, Stennett, Stephenson‐Wilson, Barrett, Bunnaman, Anderson‐Johnson, & Wint, 2016).

Health History; the current state, past illness surgeries, hospitalizations, herbal supplements, allergies, over the counter medications and common practices such as smoking, drug use, and alcohol use. Family account; includes age, the health position of parents, siblings, and children. This paper would, concentrate on performing a head to toe evaluation among the elderly patients (Wilkinson et al., 2016).

Head to Toe evaluation among elderly patients

Evaluations among the elderly are different from the normal medical appraisal. Older patients, particularly the very old, taking their health history and physical checkup ought to be done at different periods, and the process may have to be divided into two sessions because the patients could become fatigued quickly. Senior patients usually have different health problems and also exhibit multiple disorders that may need various drugs. This also increases the risk of allergies and side effects related to drug use. (Lindo, Stennett, Stephenson‐Wilson, Barrett, Bunnaman, Anderson‐Johnson, & Wint, 2016). Diagnosing elderly patients may be complicated and lead to missed or erroneous diagnoses, leading to an inappropriate administration of drugs. Early uncovering of problems can result in a prompt intervention that can prevent worsening of a condition and increase their life span, through low-cost and simple interventions such as change of diet and lifestyle (Mahaffey & Robertson, 2017).

Multiple Disorders

An average senior patient has six diagnosable ailments, and the doctor may be unaware of all these conditions. A disease in a tissue can lead to additional disorder in another system which can weaken both the organs and the patient, leading to disability, dependence and if not looked into can lead to death. Multiple disorders in a patient complicate the treatment process (from diagnosis to intervention). The effects of these diseases are overblown by social disadvantages such as isolation, poverty and lack of social supportive social welfare (Wilkinson et al., 2016). The diagnosis process among the elderly has mostly been compromised by the lack of funds to support some process, which would otherwise have improved the condition of the senior patient. The nurse should pay attention to some common geriatric symptoms such as mobility problems, loss of appetite, syncope, inconsistency in urinating, dizziness, weight loss, and delirium. These symptoms may be an outcome of multiple organ failures. In case a nurse is dealing with various disorders, interventions such as bed rest, surgery and drugs should be integrated efficiently; because treating one disorder without considering the other may accelerate the decline. Mahaffey & Robertson (2017) add that besides, a thorough monitoring system needs to be placed in a place to avoid iatrogenic effects. For instance, with a holistic rest, senior patients can lose about 1 to 3% of muscle mass and strength each day, which eventually causes sarcopenia, and the impacts of bed rest only could subsequently lead to death.





Possible condition


Oily/ Dry skin (but not breaking)

Breaking skin, Itchy skin

Cancer, uremia, dry skin, jaundice, scabies, lice, hyperthyroidism, allergy


No pains or swellings


Tumors, anxiety, depression, subdural hematoma, cervical osteoarthritis


Central and clear vision, No eye pains, normal adaptations to light.

Presbyopia, Insufficient central vision, Glare from lights at night, loss of, Pain in the eye

Stroke, temporal arteritis, cataracts, glaucoma, macular degeneration, Enormous cell arteritis


Normal audible range

Loss of hearing, presbycusis

External tissues in the auditory system, curemen, acoustic neuroma, viral infection, cerebellopontine tumor, Paget infection, trauma


No pains and bleeding

Denture pain, burning mouth,

Dry mouth, loss of taste

Constricted tongue motion

Loss of taste

Stomatitis, Pernicious anemia, poorly fitted dentures, oral cancer

Infections that can damage the salivary glands, radiation therapy for head and neck tumors, dehydration,

Stroke, Cancer, Autoimmune illness such as (RA, SLE, Sjogren Syndrome)

Drugs (psychoactive drugs, diuretics, antihypertensive)

Adrenal deficiency, medications (for example, antihistamines, antidepressants), radiation therapy, mouth infection, nasopharyngeal tumor, xerostomia, smoking


Normal and constant tonal variation

No pain


Unpredictable voice changes

Foreign body, stroke, anxiety, cancer

Voice cord tumor, hypothyroidism, laryngeal system malfunction


No pain




Cervical arthritis

Polymyalgia rheumatic,

Carotid or vertebral artery dissection,


No pain

Normal breaths

Paroxysmal nocturnal dyspnea

Chronic cough

shortness of Breath

Dyspnea in physical exertion



Functional deterioration

Heart attack


chronic obstructive pulmonary disease

Angina pectoris, aortic dissection, food pipe motility disorders, costochondritis, pneumonia, Anxiety, pleuritis, gastroesophageal reflux, pleural effusion, herpes zoster, myocarditis pericarditis


Normal bowel movement

No abdominal pains

No bleeding


Constipation plus diarrhea and vomiting.

Incontinence (fecal)

Intestinal pain

Postprandial intestinal discomfort (Occurring after 2 to 3 of eating, lasting up to 90 minutes)

Rectal bleeding

Cancer, hypercalcemia, dehydration, inadequate exercise, laxative abuse, low-fiber intake, drugs Fecal impaction, bowel blockade

Cerebral dysfunction, spinal cord lesions

gastroenteritis, obstruction

rectal cancer, fecal impaction, Diverticulitis, ischemic colitis, Chronic intestinal ischemia

Hemorrhoids, Large interstines angiodysplasia, diverticulosis, ischemic colitis, colon cancer,


No pain

Normal urinary consistency

Urinary certainty

Urinary regularity, Urinary uncertainty incontinence

Frequency, dribbling, hesitancy, weak stream

Dysuria with or without fever



Benign prostatic hyperplasia (BPH), detrusor instability, estrogen deficiency, BPH

Benign prostatic hyperplasia, urinary retaining, UTI, prostate cancer, constipation drugs

Prostatitis, UTI

Diabetes insipidus diabetes mellitus, diuretics

Cystitis, functional failure, UTI, , urinary retention or overflow, stroke, spinal cord dysfunction, normal-pressure hydrocephalus


Back Pains

Proximal muscle pain/weakness

Pain on joins

Abdominal aortic aneurysm, Paget disease, pyelonephritis, compression fractures, infection, multiple myeloma, osteoarthritis, spinal stenosis, metastatic cancer

Myopathies, polymyalgia rheumatic, use of statins


No pains

No inflammations

Pain in the legs

Swollen ankles

Recurrent claudication, osteoarthritis, agitated legs condition, night cramps

Heart failure, hypoalbuminemia, venous inadequacy, renal insufficiency



Normal motor movement



Change in mental status with fever

Change in psychological condition without fever

Clumsiness in tasks requiring excellent motor coordination

Extreme sweating when eating

Fall devoid consciousness

Hesitant gait with intention tremor

Sleep disturbances


Delirium, sepsis

encephalitis, meningitis

Acute illness, fecal impaction, fever, depression, cognitive dysfunction, drugs, paranoia, urinary retention

Arthritis, spondylotic cervical myelopathy, parkinsonism, intention tremor.

Autonomic neuropathy

Carpal tunnel condition, spondylotic cervical myelopathy

Alcohol abuse, CNS disorder), essential tremor, parkinsonism, hyperthyroidism


Haugh, K. H. (2015). Head-to-toe: Organizing your baseline patient physical assessment. Nursing2016, 45(12), 58-61.

Lindo, J., Stennett, R., Stephenson‐Wilson, K., Barrett, K. A., Bunnaman, D., Anderson‐Johnson, P., ... & Wint, Y. (2016). An Audit of Nursing Documentation at Three Public Hospitals in Jamaica. Journal of Nursing Scholarship, 48(5), 499-507.

Mahaffey, P. J., & Robertson, M. (2017). Adult simulation and demonstration of nurse competency with neurological assessment. Journal of Vascular Nursing, 35(1), 38-41.

Wilkinson, J. M., Treas, L. S., Barnet, K. L., & Smith, M. H. (2016). Procedure Checklists for Fundamentals of Nursing. FA Davis.

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