Head to Toe Assessment

Topic Technique Area(s) Assessed Technique Findings

Items BP cuff, Rosenbaum chart, penlight, tongue depressor, smelling agent, cotton balls, long q-tip (sharp & dull), reflex hammer, gloves, hand sanitizer, watch
Wash Hands Put on gloves, provide privacy, adjust bed height. Client puts on gown. Clean stethoscope prior to 1st use
Introduce Self Hello, my name is ( ) and I’m going to be your student nurse.
Explains Today I will be performing a head to toe assessment which consists of inspecting, touching, lightly tapping, and listening with a stethoscope.
Assessment to ALSO, FOR THE SAKE OF TIME TODAY, I WILL ONLY BE ASSESSING ONE EYE, EAR, AND NOSTRIL.
Client *PERFORM HAND HYGIENE*
Mental Status Inspect Orientation (3 Include 3 parts of orientation Patient is alert to person, place, situation, and year.
assessments)  Can I please have your full name with middle initial? Do Pt. is oriented x4
you know where you are right now and why are you at
this place and what year it is?
Emotional assessment  Are you able to deal with stressors? Pt. is able to deal with stressors.
Cultural (1 assessment)  Are we meeting your cultural needs? Pt. cultural needs are met
Spiritual (1assessment)  Do you believe in a higher power? Pt. believes in a Higher power.
Vital Signs Inspect, Heart Rate  Rhythm  “Next I will be taking your vital signs. Normally, I normal range: 60-100
Palpate, Normal Range  would count for 30 sec and multiply by 2 to assess both Heart rate is 76. Regular and even rhythm
Auscultate respiratory and heart rate, but for today I will only be 19 x 4 = 76
Resp. Rate  Rhythm  counting for 15 seconds and multiplying by 4.” normal range: 12-20
Normal Range  Resp. rate is 16. Regular and even rhythm
4 x 4 = 16
Manual BP  Follow checklist for BP checkoff For the PSP I got 110 so Ill pump to 130.
*Required Assessment “I will now take your blood pressure. First, I will
measure the width and length of the cuff. Width is at blood pressure is 115 /75 and is within the normal
least 40% and Length of the bladder is at least 2/3. The range between 90/60 and 120/80.
size is correct. I will ask that you relax your arms, place
your feet flat on the ground, uncrossed, try to stay still
and silent.”
° Find brachial pulse
° Place BP cuff over brachial pulse
° Find PALPATORY SYSTOLIC PULSE and pump until it
is no longer palpable
° STATE: normally I would wait 30 seconds after to take
BP but for today I will not. **
° Pump 20-30 over the # it stopped at
° Begin auscultating
Head Inspect, Skull (size & symmetry) Now I’m going to assess your head. - Head is normocephalic, and symmetrical
Palpate  put hands in hair and palpate skull - Facial features are symmetrical and placed
Facial Structures accordingly
(symmetry) 

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Eyes Inspect Conjunctiva  Pt. looks up and you pull down on the lower eye lids Conjunctive is clear, transparent, and moist
Sclera  Sclera china white, and smooth
Visual Acuity  “Next I will be testing visual acuity using the Patient’s vision in her right eye is 20/20 with
Rosenbaum chart. Read the smallest row you’re able to corrective lens
read”
Please hold it 14 inches away from you.
Pupils – PERRLA  “Now I will test PERRLA which means pupils are equal, “Pupils are equal, round, and there was direct
round, reactive to light and accommodation.” reaction in right eye and consensual reaction in left
Direct Reaction  Can you look straight ahead for me? I am going to be eye. So, they are reactive to light. Pupils
Consensual Reaction  looking for a direct reaction in her right eye and accommodate by both constriction and
*penlight consensual reaction in her left. convergence.”
Accommodation  “focus on something in the back and now follow my
finger”
Ears Inspect Auricle/ Ear Canal  *Shines penlight* Look inside ear with pen light; pull Ears are symmetrical. Inner ear canal is patent
*penlight pinna up and back
Palpate Auricle  I’m going to move the pinna and push on the tragus, No cerumen, lesions, or redness. Patient states no
palpate mastoid process (behind ear). Do you feel any tenderness
pain or tenderness?
Nose Inspect External Nose  Look at nose External nose is symmetrical, midline, and
proportional to face. No deviations or lesions
noted
Patency of Nostrils  Occlude on one nostril and breathe in Nostrils are patent
Mouth Inspect Lips  Look at lips Pink, moist, intact, free of lesions
*Gloves, Buccal Mucosa  Open mouth look around with penlight and tongue Pink, smooth, moist, free of lesions
penlight, depressor to depress lower/upper lip
tongue Gums  Use tongue depressor to pull down on lips Gums are pink, moist, intact, tight margins with the
depressor Teeth  teeth. Teeth are all present, are free of decay, white
Neck Inspect Neck (symmetry)  I will now assess your neck. neck is midline, symmetrical to body with no
masses noted
Palpate Trachea  Using index finger: Find super sternal notch, slide up 1in Trachea is midline, no tracheal shift present
on both side feeling for soft, smooth
Nervous Inspect & Olfactory – CN I  Now I will assess the nervous system. Pt. is able to identify scents correctly, CN 1 is
System Palpate Cranial Nerve 1 is the Olfactory nerve and its function intact
*name is smell.
&number - Occlude one nostril, close eyes, and tell me what you
worth 0.25 smell. (do with both nose)
each.
Functions
worth 0.5 total
(must include Optic – CN II  Cranial Nerve 2 is the optic nerve and its function is completely extend/stretch arm, come from behind

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all functions visual acuity. pt f/f; both person covers same eye
for credit) - I already tested visual acuity using the rosenbaum say “now” when you see my fingers (3 on left),
chart. switch HAND (1 on right) “say now.”
- I would also use an ophthalmoscope, but I will not do
so today.
- So now I will assess peripheral vision using Patient’s peripheral field is full and demonstrates
CONFRONTATION test visual acuity. CN 2 is intact
Oculomotor – CN III  Cranial Nerves 3,4, and 6 are tested together. They are
Trochlear – CN IV  the Oculomotor, Trochlear, and Abducens nerve and
Abducens – CN VI  their function is eye movement.
3 P’s test - PERRLA, Palpebral Fissures, Parallel
tracking
- I have already tested eye movement using PERRLA.
- “Inspect palpebral fissures” have pt. blink (outer- - Patient’s palpebral fissures are equal in width.
corner of eye) - Patient demonstrates parallel tracking with no
- “I will assess parallel tracking using the cardinal nystagmus noted.
fields of gaze test.” CN’s 3,4, and 6 are intact.”
Trigeminal – CN V  “Cranial Nerve 5 is the Trigeminal nerve and its - Motor: Muscles are equally strong on both
(motor & sensory) function is sensation of the face.” sides. I was unable to open jaw which is a
- Motor: Can you clench jaw as I palpate temple and normal finding.
jaw. Keep jaw clenched” - try to open jaw by pulling - Sensory: Client was able to identify when face
on chin. was touched, CN 5 is intact.
- Sensory: Close your eyes and say now when you feel
the cotton ball touch your face (forehead, cheek,
chin; 1 side of face).
Facial – CN VII  “Cranial Nerve 7 is the Facial nerve and its sensory “Facial movements are equal, and symmetrical
function is taste but I will not be assessing that today. its with no signs of weakness and air escapes equal
motor function which is facial movements.” bilaterally. Cranial nerve 7 is intact.”

- Please smile, frown, raise eyebrows, and puff out

your cheeks. *pt. can press on cheeks for air to
escape
Acoustic – CN VIII  “Cranial Nerve 8 is the Acoustic nerve and its function You stand 2 ft. behind pt. whisper 3 words (2
is hearing acuity.’ syllable words) and pt. repeats all 3

- Whisper voice test - “Patient was able to correctly repeat the 3

please tap your tragus and repeat the three words I will be words. CN 8 is intact.”
whispering to you. Chicken, music, and sleeping.
Glossopharyngeal – CN – Cranial Nerve 9 and Cranial Nerve 10 are tested - “So, I’ve been communicating with the client
IX  together. throughout our assessment so I know her
Vagus – CN X  – CN 9 is the Glossopharyngeal nerve. I will not speech is smooth and unstrained, so CN 9 is

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 *gloves* assess the gag reflex. So, its motor function is intact.”
speech” - “Uvula and soft palate both rise midline,
– CN 10 is the Vagus nerve. and its motor function is tonsils moved medially, and her swallow was
swallowing. effortless, so CN 10 is intact.”
*wash hands, new gloves, tongue depressor, pen light *
- *Depress tongue and shines penlight* Please say
“ahh” for me. OK now swallow for me please.
Spinal Accessory – CN Cranial Nerve 11 is the Spinal Accessory Nerve and Client was able to resist with equal strength
XI  its function is movement of the trapezius and bilaterally against resistance, CN 11 is intact.
sternocleidomastoid muscles.”
- Press hand against pt. face, push against
resistance, left/right.
- Hold down shoulders, shrug your shoulders
Hypoglossal – CN XII  Cranial Nerve 12 is the Hypoglossal Nerve and its - No wasting or tremors present, tongue is
function is tongue movement.” midline.
- Have pt. stick out tongue - Letters L, T, D, and N are clear and distinct.
- Have pt. say LIGHT, TIGHT, DYNAMITE.” CN 12 is intact.
SAY “CRANIAL NERVES 1-12 ARE INTACT.
Motor System Inspect Gait  Please walk in a straight line and back, walk back heel to Gait is smooth, coordinated, and effortless.
toe.
Palpate Grip  Can I have you squeeze my fingers for me? Can you push Muscle strength is equal bilaterally
against my hands for me?
Sensory Inspect Light Touch  I will now assess your sensory system by testing light Client can identify light touch and pain by
System touch & pain distinguishing between sharp and dull.
Please close your eyes and say now when you feel the
cotton ball (upper and lower arm and leg).
Pain  With your eyes closed I am going to touch you with
something sharp and dull. Please differentiate which is
which.
Reflexes Inspect Biceps  Now I’m going to assess biceps reflexes. She has a bicep reflex of 2+.
perform Have arm relax on your arm with thumb on her
reflexes antecubital space and hit top of thumb with pointed edge
unilaterally Patellar  (quadriceps Patellar Reflex She has a patellar reflex of 2+
reflex) Sits down with relaxed legs, not touching floor and hit
below the patella with wide edge

Plantar Response  Elevate food on bed Client tested negative for Babinski
Now I am going to check your plantar reflex by making *Bonus Point
an upside-down J on your foot. 4+ Very brisk

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 Start at heel and move up toward big toe 3+ Brisker than average
2+ Average
1+ Diminished
0 No response
Skin Inspect Color  I am now going to assess your skin. Skin tone is even throughout body
Pg. 207-214 Palpate Temperature  *Assess with back of hand on extremities, forehead, and Skin feels warm and equal bilaterally
neck bilaterally
Edema  Now I will assess for edema, Ankle No edema present
test any were you want, press down for 4-5 seconds,
count out loud.
Turgor  Now I will be assessing skin turgor. no tenting present
*Pinch skin under clavicle*
Thorax & Inspect Chest (shape Include both shape and configuration - Posterior chest is symmetrical and with
Lungs &configuration)  I am now inspecting your anteriorposterior to transverse downward sloping ribs. No barrel chest
Posterior diameter - AP: T has a ratio of 1:2
Chest Palpate Chest (tenderness & *Palpate posterior side*
Lungs: 12 masses)  Do you feel any tenderness and feel for masses? There is no tenderness or masses present.
sites Auscultate Chest (breath sounds) Please take a deep breath every time you feel my Vesicular sounds were heard over peripheral lung
DO NOT stethoscope touch your back fields and bronchovesicular sounds were heard
listen over Vesicular  Starts high, ends at T10 at end of ribs over major airways. Lung sounds are clear and
clothes Bronchovesicular  equal bilaterally. I heard no adventitious sounds.

Peripheral Palpate Pulse Sites State pulse name that you are palpating. *Bonus Points
Vascular *Assess pulse bilaterally with two fingers* 3+ bounding
System 2+ is normal
*supine 1+ is weak
position 0 is absent.
Carotid  One at a time, lower half of the neck All pulse sites were a 2+
Brachial 
Radial 
Dorsalis Pedis  Medial aspect of the ankle
Posterior Tibia 
Inspect Vascularity  Normally I would assess vascularity. No varicosities present.
Inspect legs, front and back, have pt. stand
Inspect & Capillary Refill  Now I am checking for capillary refill. Can I see your Capillary refill is normal and color returns in less
Palpate nails? Press on nails than 2 seconds.
Heart Inspect Precordium  (apical *Check 5th ICS, midclavicular line* Apical impulse visible/not visible, no heaves are
*supine impulse & heaves) I will be inspecting your precordium…” visible

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position Auscultate Identify Heart Sounds “I will be auscultating heart sounds now. I will go over Use Diaphragm (down) & then use Bell (up) 
once with the diaphragm and back with my bell.
Normally, I would auscultate aortic, pulmonic, Erb’s
point, and tricuspid for 30 seconds, and mitral for 60
seconds but today I will only listen for a couple of
seconds.”
Aortic Area  Identify name and location prior to auscultating all sites Include rhythm & all sounds at each site
Pulmonic Area  ● Aortic Area: right 2nd ICS at sternal border Identify appropriate sounds heard
Erb’s Point  ● Pulmonic Area: left 2nd ICS at sternal border Heard S1 and S2 in all the areas, rhythm is regular
Tricuspid Area  ● Erb’s point: 3rd ICS at left sternal border in all the areas. With the Bell s3, s4 and murmurs
Mitral Area  ● Tricuspid Area: left 4th ICS at sternal border were not heard. I heard S2 louder at base (top), and
● Mitral Area: 5th ICS at medial to midclavicular line S1 louder at apex (bottom).
Abdomen Inspect Abdominal Contour  Be eye level with abdomen Contour is flat. Slight pulsation noted over
*supine Abdominal Pulsations  Aortic pulsation; can/can’t see depending on pt. abdominal aorta.
position Auscultate Bowel Sounds  Now I am going to listen for bowel sounds over RLQ. Bowel sounds were heard in RLQ which means it
is present in all four quadrants. If they were not
present in RLQ, I would have listened for a full 5
minutes in all quadrants before I document for
absent sounds.
Percuss Abdomen (general tone) Middle to middle finger, strike 2 times Tympany is heard throughout.
 Percuss in a zig zag motion in all 4 quadrants moving
clockwise*
Go in a zig-zag in each quad
Light Abdomen (all 4 *Four fingers in circular motion* No pain, tenderness or induration noted. Muscle
Palpation quadrants)  Now I am going to lightly palpate all four quadrants and tone is firm with no guarding present.
assess for muscle tone and any tenderness. Please let me
know if you feel any tenderness.
THIS CONCLUDES MY HEAD TO TOE ASSESSMENT.

Patellar (quadriceps) reflex

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