NLE Health Assessment — Systematic Head-to-Toe & Body-System AssessmentConcept Map

Concept

Assessment Foundation & Principles

Sub Concepts

• Cephalocaudal (head-to-toe) direction
• Bilateral comparison for symmetry
• IPPA techniques (Inspection, Palpation, Percussion, Auscultation)
• Energy conservation and positioning
• Privacy, warmth, and standard precautions
• Equipment preparation

Relationship To Central

Establishes the framework and preparation for conducting a systematic assessment

Concept

Integumentary System Assessment

Sub Concepts

• Skin color, temperature, moisture, turgor
• Capillary refill time
• Hair distribution and quality
• Nail appearance and clubbing
• Lesions, edema, cyanosis, jaundice
• Abnormal findings: poor turgor, tenting, pallor, central cyanosis

Relationship To Central

First region examined; serves as indicator of systemic health and perfusion

Concept

Head, Face, and Neck Assessment

Sub Concepts

• Head normocephalicity and symmetry
• Facial symmetry and CN VII function
• Tracheal midline position
• Thyroid palpation and size
• Lymph node assessment (location, size, texture, mobility)
• Red flags: facial droop, tracheal deviation, enlarged/nodular thyroid

Relationship To Central

Evaluates cranial nerve function and identifies structural abnormalities

Concept

HEENT Assessment (Eyes, Ears, Nose, Throat)

Sub Concepts

• Eyes: PERRLA, pupil size, sclera assessment, visual acuity, extraocular movements
• Ears: pinna alignment, tympanic membrane integrity, hearing assessment
• Nose: septum position, nasal mucosa color, discharge
• Throat: tonsil size, uvula position, gag reflex, cranial nerves II-XII screening
• Abnormal findings: anisocoria, fixed pupils, icteric sclera, otitis media, uvula deviation

Relationship To Central

Comprehensive sensory and respiratory gateway examination

Concept

Respiratory System Assessment

Sub Concepts

• Respiratory rate and effort
• Chest symmetry and expansion
• Anteroposterior-to-transverse ratio
• Percussion findings (resonance, dullness, hyperresonance)
• Normal breath sounds: vesicular, bronchovesicular, bronchial
• Adventitious sounds: crackles, wheezes, rhonchi, pleural friction rub, stridor
• Red flags: stridor, absent breath sounds, barrel chest, decreased SpO2

Relationship To Central

Critical airway and gas exchange evaluation using thoracic landmarks

Concept

Cardiovascular Assessment

Sub Concepts

• PMI (point of maximal impulse) location
• Heart sounds: S1 (AV valves), S2 (semilunar valves)
• Auscultation sequence: APE To Man (Aortic, Pulmonic, Erb's, Tricuspid, Mitral)
• Murmurs and extra sounds (S3, S4)
• Pulse assessment: rate, rhythm, quality (0-3+)
• Peripheral vascular: bilateral symmetry, warmth, pulses, edema
• Edema grading (1+ to 4+) and location significance

Relationship To Central

Evaluates perfusion and cardiac function via auscultation and palpation

Concept

Abdominal Assessment

Sub Concepts

• Modified IPPA sequence: Inspect, Auscultate, Percuss, Palpate
• Bowel sound assessment (5-30/min normal)
• Percussion findings (tympany, dullness)
• Palpation: soft vs. rigid, tender areas, rebound tenderness
• Liver span and hepatomegaly
• Red flags: hyperactive/hypoactive/absent bowel sounds, pulsatile mass, rigid abdomen

Relationship To Central

Modified sequence examination critical for detecting acute and chronic pathology

Concept

Breasts and Axillae Assessment

Sub Concepts

• Breast symmetry and skin assessment
• Nipple assessment (eversion, retraction, discharge)
• Palpation for masses and tenderness
• Axillary lymph node assessment
• Red flags: fixed hard masses, dimpling, peau d'orange, bloody discharge
• Promotion of monthly breast self-examination

Relationship To Central

Screens for malignancy and teaches health promotion behaviors

Concept

Musculoskeletal Assessment

Sub Concepts

• Range of motion (ROM) and limitations
• Muscle mass and symmetry
• Muscle strength grading (0-5 scale)
• Gait observation and balance
• Joint swelling, deformity, and crepitus
• Posture and spinal alignment

Relationship To Central

Evaluates mobility, strength, and structural integrity

Concept

Neurologic Assessment

Sub Concepts

• Level of consciousness via Glasgow Coma Scale (GCS)
• Orientation to person, place, time
• Cranial nerves II-XII assessment
• Deep tendon reflexes (0-4+ scale, 2+ normal)
• Plantar reflex (flexor/upgoing)
• Sensation testing
• Coordination and balance (Romberg test)
• Mental status: appearance, behavior, cognition, mood
• Red flags: declining LOC, Babinski reflex (adult), nuchal rigidity, FAST criteria

Relationship To Central

Comprehensive CNS evaluation including consciousness, cranial nerves, reflexes, and sensation

Concept

Genitourinary and Reproductive Assessment

Sub Concepts

• Bladder distention and post-void residual
• Urine output assessment (0.5-1 mL/kg/hr normal)
• Urine characteristics (color, clarity, odor)
• External genitalia inspection
• Red flags: oliguria, anuria, hematuria, cloudy/foul urine, abnormal discharge

Relationship To Central

Screens for infection, retention, and abnormal findings

Concept

Prioritization and Red-Flag Recognition

Sub Concepts

• ABC priority lens (Airway, Breathing, Circulation)
• Immediate action required findings
• SBAR communication with physician
• Nursing diagnosis linkage to assessment findings
• Compliance with RA 9173 accountability standards
• Documentation standards

Relationship To Central

Framework for determining urgency and appropriate reporting of abnormal findings

Concept

Assessment-to-Intervention Bridge

Sub Concepts

• Abnormal finding interpretation
• NANDA nursing diagnosis development
• Maslow-based prioritization of care
• Nursing care planning and intervention selection
• Evaluation of intervention effectiveness
• Collaboration with interdisciplinary team

Relationship To Central

Links physical findings to nursing process and clinical decision-making

To

All Body Systems Assessment

From

IPPA Techniques Foundation

Strength

strong

Relationship

These four techniques are applied systematically across every body region and system

To

Assessment Preparation

From

Cephalocaudal Sequence

Strength

strong

Relationship

Proper preparation enables efficient head-to-toe flow with minimal repositioning

To

Red Flag Recognition

From

Integumentary System

Strength

strong

Relationship

Skin findings like central cyanosis, jaundice, and poor turgor are systemic indicators requiring immediate assessment of other systems

To

Neurologic Assessment

From

HEENT Assessment

Strength

strong

Relationship

Cranial nerves II-XII are screened during HEENT; detailed neurologic exam follows and expands this evaluation

To

Red Flag Recognition

From

Respiratory Assessment

Strength

strong

Relationship

Abnormal breath sounds (crackles, wheezes, stridor) and absent/diminished findings are critical red flags requiring immediate reporting

To

Perfusion Status

From

Cardiovascular Assessment

Strength

strong

Relationship

Heart sounds and peripheral pulses collectively indicate perfusion adequacy and cardiovascular function

To

Modified IPPA Sequence

From

Abdominal Assessment

Strength

strong

Relationship

Abdomen uses a specific sequence modification (Inspect-Auscultate-Percuss-Palpate) different from standard IPPA to preserve bowel sound assessment

To

Level of Consciousness

From

Neurologic Assessment

Strength

strong

Relationship

Glasgow Coma Scale provides objective measurement of consciousness level, a core component of neurologic exam

To

ABC Priority Framework

From

Red Flag Recognition

Strength

strong

Relationship

Red flags are systematically prioritized using ABC framework to determine urgency of intervention

To

SBAR Communication

From

Abnormal Finding

Strength

strong

Relationship

All abnormal findings must be documented and reported using SBAR format per nursing communication standards

To

NANDA Nursing Diagnoses

From

Assessment Findings

Strength

strong

Relationship

Physical assessment findings drive the development of accurate, data-supported nursing diagnoses

To

Maslow-Based Prioritization

From

NANDA Nursing Diagnoses

Strength

strong

Relationship

Nursing diagnoses are organized according to Maslow's Hierarchy for care planning and intervention prioritization

To

RA 9173 Compliance

From

Documentation

Strength

strong

Relationship

Accurate assessment documentation is a legal and ethical requirement under Philippine nursing practice law RA 9173

To

Abnormality Detection

From

Bilateral Comparison for Symmetry

Strength

moderate

Relationship

Comparing left-to-right sides helps identify localized vs. systemic abnormalities and catches subtle findings

To

Client Positioning Sequence

From

Energy Conservation

Strength

moderate

Relationship

Grouping assessments by position minimizes repositioning and conserves energy especially for critically ill clients

To

Health Promotion

From

Breasts and Axillae Assessment

Strength

moderate

Relationship

Assessment provides opportunity to teach breast self-examination and screening importance

To

Perfusion Status

From

Urine Output Assessment

Strength

moderate

Relationship

Adequate urine output 0.5-1 mL/kg/hr indicates adequate renal perfusion and cardiac output

To

Neuromuscular Function

From

Deep Tendon Reflexes

Strength

moderate

Relationship

DTR assessment reveals integrity of reflex arc and neurologic function at spinal cord level

To

Therapeutic Relationship

From

Client Privacy and Warmth

Strength

weak

Relationship

Maintaining dignity and comfort during assessment builds trust and encourages accurate reporting of symptoms

To

Infection Prevention

From

Standard Precautions

Strength

moderate

Relationship

Consistent use of gloves, hand hygiene, and precautions prevents healthcare-associated infections during assessment