Head to Toe Assessment

Head to Toe Assessment


Mrs. A is a 57-year-old female who presented to the ED via EMS with complaints of ear pain for the past two days. She states that the pain stopped this morning when she felt like yellow “stuff” was coming out of her ear. She has a history of hypertension, diabetes mellitus, and arthritis. She reports a family history of hypertension and CAD. Medications include Metoprolol 10mg daily PO, and Metformin 500mg two times daily PO. This paper will provide a detailed management system of the chosen participants. The management will entail a head to toe assessment of the patient, review of the systems, diagnosis, the plan of care, and the health promotion techniques that will be used for Mrs. A.

Head to toe assessment

General appearance

Mrs. A  is a short woman; she appears to be moderately obese. The patient is animated and is fast in her response to questions. She looks to be tense, and her hands feel moist and cold. Her hair is kept well, and her clothes are clean and neat. Her skin complexion is good, and she is lying flat on the examination bed and does not seem to have any discomforts in doing that.

Vital signs

The patient is found overweight at 195lb measuring 5 feet, 2 inches.Vital signs reveal a temp of 101.6, BP 167/82, RR 18, and HR 89. A1C is 4, BS 110. (Oral).


The patient’s palms feel cold and are moist; the color is, however, right. She has scattered cherry angiomas all over her upper trunk. Her nails are not clubbed and are not cyanotic.


Head, Eyes, Ears, Nose, Throat:

  • Head: The client’s hair is of medium texture, there are no visible lesions on her scalp, and her scalp is normocephalic too.
  • Eyes: she has a vision of 20/30 in each eye. Her vision is confirmed to be full by confrontation. She has a pink conjunctiva and a white sclera. Her pupils constrict from 4mm to 2mm, they are round, react to light, regular and evenly shaped. The extraocular movements are still intact.
  • Ears: there is the wax that is partially obscuring the right tympanic membrane. Herr left canal is clear. The patient has a right acuity to whispered voice. Her Weber’s test is midline.
  • Nose: Her nasal mucosa is pink, her nasal septum is midline. There is no tenderness in any of her sinuses.
  • Mouth: Oral mucosa is bright pink, the patient has many interdental papillae which appear red and are slightly swollen. She has all her teeth; her tongue is midline. The patient has the white ulcer on the hard palate, there no tonsils, and her pharynx is without exudates.


The patient’s neck is supple; her trachea is located midline.

Thorax and lungs

The chest appears symmetric and has the right excursion. The lungs are resonant. The patent’s breath sounds are vesicular with no additional sounds heard.


The patient’s Jugular venous pressure is noted to be one centimeter above her sternal angle when her head is raised to thirty degrees. She has excellent S1, S2; no S3 or S4. No diastolic murmurs were heard.


Mrs. A ’s breasts are symmetrical, pendulous; they have no masses, and her nipples have no discharges.


Appears to be obese, there is a scar that is well healed in the right lower quadrant. Her bowel sounds are active. There are no palpable masses nor is there tenderness elicited. Her liver is palpable; it has a 7 cm span. Her kidneys and spleen are not palpable.


The patient’s external genitalia does not have any lesions. She has a mild cystocele at the introitus seen on straining. The mucosal membrane in the vagina is pink. Her cervix is pink, does not have any discharge and is parous.


The patient’s rectal vault does not have any masses; her stool is brown and is found to be negative for occult blood.




Extremities are warm and do not have edema or any other deformities. The patient’s calf is supple and is not tender.

Peripheral vascular

The patient has trace edema on both ankles. The saphenous veins of both extremities have moderate varicosities.


The patient has no deformed joints; she also has a good range of motion in her wrists, elbows, knees ankles, spine, hips, and shoulders.


Her mental status reveals she is tense but still alert and cooperating. She is coherent in thought and well oriented to time and place and person. (Yudkowsky et al., 2004)

Review of systems

    Integumentary: there are no rashes or lesions, color is right, and hair is the right cover, excellent texture and brown. Her nails are not clubbed and have no cyanosis.

    Respiratory: there is no cough or wheezing, or shortness of breath.

    Cardiovascular: the patient has no known heart disease, her blood pressure is normal as compared to her last blood pressure. She is not dyspnoeic, not orthopnea, chest pains, or palpitations.

    Gastrointestinal; the patient’s appetite is good; she has no nausea, and she is not vomiting. The patient gets bowel movements once a day; she gets constipation when tensed. No pain, gallbladder or liver problems.

    Urinary: No dysuria, proteinuria, hematuria, or flank pain. She experiences nocturia once and with a large volume of urine produced. Once in a while loses some urine when she coughs hard.

    Genital: no signs of vaginal or pelvic infections.

    Musculoskeletal: she has lower back pain after strenuous work.

    Neurologic: no fainting, motor, and sensory function are present. Her memory is good.

    Hematologic: she is not anemic and except bleeding gums she has no history of abnormal bleeding.

    Endocrine:  the patient has no history of diabetes, thyroid disease, or temperature imbalances

    Psychiatric: the patient has never been depressed, or treated for any form of psychiatric disorder (Yudkowsky et al., 2004).


For a complete head to toe assessment the nurse or health care provider will require the following equipment:

  1. For the vital sign, the nurse will need a thermometer, a galipot, a watch with a second hand, a pulse oximeter, a blood pressure machine, a box of clean gloves (Yudkowsky et al., 2004).
  2. For the real head to toe examination of the patient: a stethoscope, clean gloves, sterile gloves, a working torch, a spatula, tendon hammer, pins, tape measure, weighing scale, examination couch, blankets and draw sheets, cotton wool/gauze, examination gowns, an ophthalmoscope and an otoscope (Yudkowsky et al., 2004).

Age-specific screening and immunizations

Mrs. A  was not given any age-related vaccines. She was however given estrogen supplements because of the post-menopausal effects of reduced progesterone and estrogen production on her body. The nurse conducted breast examination on the client because of her age and possible predisposition. The nurse further performed cervical cancer screening test; pap smear.

Differential diagnosis

A differential diagnosis of Acute Otitis media can be obtained from pneumatic otoscopy which will likely reveal a ruptured tympanic membrane. The culture of the discharge will reveal the type of infective agent (Kochhar, 2015).

Plan of care

  • Nursing Diagnosis: Acute Pain related to inflammation and increased middle ear pressure
  • Interventions: Administer or teach self-administration of aspirin and other analgesics as prescribed. (Sedation is usually avoided because it may interfere with early detection of intracranial complications (Kochhar, 2015). Administer or teach Mrs. A self-administration of antibiotics, as prescribed. Encourage the use of local warm compresses or heating pad to promote comfort and help resolve infectious process. Be alert for such symptoms as a headache, slow pulse, vomiting, and vertigo, which may be significant for sequelae that involve the mastoid or even the brain.
  • Nursing diagnosis: Hyperthermia related to ear infections as evidenced by elevated body temperature
  • Intervention: administer analgesics, monitor body temperature and adjust the room temperature to a cooler temperature (Kochhar, 2015).

Evaluation:  patient reports mild pain and lower body temperature; evaluation is ongoing (Kochhar, 2015).

Pharmacologic treatment

Antibiotics and corticosteroids may be administered to curb the infection and inflammation of the middle ear. If the case complicates to mastoiditis then parenteral antibiotics are indicated (Klein, 2011). Ear drops that have tobramycin, Garamycin, and quinolones such as ciprofloxacin should be instilled into the ear whenever the tympanic membrane is ruptured. Intravenous antibiotics should be able to cover the beta-lactamase organisms for instance ampicillin-sulbactam..Frequent removal of epithelial debris and purulent drainage may protect tissue from damage (Kochhar, 2015)

Evidence-based strategies for health promotion

Mrs. A will have to be taught to keep her ear dry and avoid regularly washing her hair, swimming, and showers. All of which are meant to prevent water from entering her ear. (Klein, 2011) The patient should further be encouraged to follow up for more ear cleaning. She should also regularly see her physician for physical examinations because of her past medical history of diabetes, hypertension, and arthritis. The patient should also be taught the importance to adhere to the prescribed drug regimen.  She should be advised further of the probable complications and to report a change in the mental status, increased pain in the ear or a headache (Kochhar, 2015).
















Klein, J. (2011). Is Acute Otitis Media a Treatable Disease?. New England Journal Of Medicine, 364(2), 168-169. http://dx.doi.org/10.1056/nejme1009121

Kochhar, S. (2015). Managing acute otitis media. Independent Nurse, 2015(15), 27-27. http://dx.doi.org/10.12968/indn.2015.15.27

Yudkowsky, R., Downing, S., Klamen, D., Valaski, M., Eulenberg, B., & Popa, M. (2004). Assessing the head-to-toe physical examination skills of medical students. Medical Teacher26(5), 415-419. http://dx.doi.org/10.1080/01421590410001696452