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Head to toe assessment, Study notes of Nursing

Cuyahoga Community College (also known as Tri-C)Nursing

Head to toe assessment with specific landmarks

Typology: Study notes

2024/2025

Uploaded on 03/23/2025

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megane-ngako 🇺🇸

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6/21 jlh, ech
N1220 Physical Assessment
Physical Assessment test out: 5 minutes to complete using the following sequence
Bring your stethoscope
1. LOC- person, place and time
2. Lung sounds
•Anterior (5 pairs)
•Posterior (9 pairs)
3. Heart Sounds: Auscultate for S1 and S3
•4 sites
pf3
pf4

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Physical Assessment test out: 5 minutes to complete using the following sequence

Bring your stethoscope

  1. LOC- person, place and time
  2. Lung sounds
    • Anterior (5 pairs)
    • Posterior (9 pairs)
  3. Heart Sounds: Auscultate for S1 and S
    • 4 sites
  • A t P arma T own M all Aortic Pulmonic Tricuspid Mitral

Know the anatomical landmarks of the auscultatory sites:

Aortic Valve Area – second right intercostal space (ICS)

Pulmonic Valve Area – second left intercostal space

Tricuspid Valve Area – left lower sternal border (5 th^ ICS)

Mitral Valve Area – fifth ICS at around left midclavicular line(Area you listen to apical pulse)

S1 heard the loudest at the apex (Mitral Valve Area or ApicalPulse)

S2 heard the loudest at the base (Aortic Valve Area)

  1. Abdominal sounds
    • Assess 4 quadrants for bowel sounds- start at the RLQ
    • Inspect first, auscultate then lightly palpate
  2. Pulses and strength- you are only responsible for the following
    • Radial
    • Dorsalis pedis
    • Posterior tibialis

Nursing 1220

CRITICAL SKILLS CHECKLIST FOR PHYSICAL

ASSESSMENT

NAME:

INSTRUCTOR: DATE: _

TESTER:

Student will be marked unsuccessful if critical skills are not completed and will have to retest

Completion of procedure within 5 min. Level of Consciousness- person, place, time _______

Lung Sounds:

  1. Assessed anterior lung fields. Placed stethoscope at 5 pairs of anterior auscultatory sites.
  2. Assessed posterior lung fields. Placed stethoscope at 9 pairs of posterior auscultatory sites.

S1 and S2 Auscultatory Sites:

  1. Auscultated S1 sound at various anatomic landmarks
  2. Listened for S2 sound at each site Auscultatory Sites and Landmarks:
  3. Identified aortic valve area (2 nd^ right ICS)
  4. Identified pulmonic valve area (2 nd^ left ICS)
  5. Identified tricuspid valve area (left lower sternal border, 5 th^ ICS)
  6. Identified mitral valve area (fifth ICS, left MCL)

Abdomen:

  1. Assessed bowel sounds in proper sequence starting at RLG
  2. Palpated lightly after bowel sounds

Pulses:

  1. Palpated radial pulses and assessed strength
  2. Palpated dorsalis pedis pulses and assessed strength
  3. Palpated posterior tibialis pulses and assessed strength _______ Capillary Refill
  4. Bilateral thumbs _______
  5. Bilateral toes _______