Head to Toe Assessment

What are the first steps before entering the patient's room?

Knock → Walk into the room → Provide privacy by closing the curtain/door → Perform hand hygiene before touching anything.

How do you introduce yourself to the patient?

"Hello, my name is ________. I am a student nurse. I will be performing your head-to-toe assessment today."

How do you explain the assessment?

"This assessment will involve looking, listening, and touching different parts of your body."

How do you obtain consent?

"Is it okay if I touch you during today's assessment?"

What should you tell the patient before beginning the exam?

"If you have any questions or become uncomfortable at any time, please let me know and I'll stop."

What should you ask before starting the assessment?

"Do you have any questions before we begin?"

What identification questions do you ask during the general survey?

"Can you tell me your full name and date of birth?"

How do you assess orientation to place?

"Do you know where you are today?"

How do you assess orientation to time?

"What month and day is it today?"

What allergy question should you ask?

"Do you have any allergies?"

What cultural question should you ask?

"Do you have any cultural considerations I should know about?"

How do you determine the chief complaint?

"What brought you in today?"

What should you observe during the general survey?

Appearance, hygiene, facial symmetry, speech, respiratory effort, gait, movement, level of consciousness, and overall distress.

What should you verbalize after the general survey?

"Patient is alert and oriented ×4. Glasgow Coma Scale is 15. Patient appears healthy for age. Face is symmetrical. Eyebrows evenly distributed. Skin color appropriate for ethnicity. Weight appropriate for height and frame. Gait is steady. Patient is dressed appropriately for the season. No cardiac or respiratory distress. Patient moves freely in bed. Patient has ______ allergies and ______ cultural considerations. Chief complaint is ______."

What do you do before beginning the physical exam?

Inform the patient that the assessment is beginning.

How do you assess the hair and scalp?

Inspect the hair and scalp, then palpate the scalp using your fingertips for lumps, bumps, lesions, or scars.

What should you say during the hair and scalp assessment?

"Head is normocephalic. Hair is evenly distributed. No lumps, bumps, lesions, scarring, flaking, or dryness."

What do you inspect during the skin assessment?

Color, integrity, lesions, bruising, rashes, cyanosis, pallor, jaundice, scars, and overall condition.

How do you assess skin temperature?

Use the dorsal surface of both hands to compare temperature down both arms and both legs.

How do you assess capillary refill?

Press the nail bed for about 5 seconds, release, and observe for refill in less than 2 seconds.

How do you assess skin turgor?

Pinch the skin over the clavicle, lift, release, and observe that it immediately returns to normal without tenting.

What should you say during the skin assessment?

"Patient's skin is warm, dry, clean, and intact. No cyanosis, pallor, or jaundice. No lumps, bumps, lesions, or scarring. Capillary refill is less than 2 seconds bilaterally. Nail angle is less than 160 degrees. No clubbing. Skin returned to its original state in less than 2 seconds. No tenting noted."

How do you assess PERRLA?

Have the patient look straight ahead. Shine the penlight from the side into each eye. Assess pupil size, equality, and reaction to light, then assess accommodation.

How do you assess extraocular movements?

Have the patient follow your finger through the six cardinal fields of gaze in an H pattern, then look up and down.

How do you inspect the conjunctiva?

Gently pull down the lower eyelid and inspect the conjunctiva.

What should you say during the eye assessment?

"Pupils are equal, round, and reactive to light and accommodation. Pupils measure approximately 3 mm. Conjunctiva is pink and moist. Sclera is white. Cornea has no opacities. Lacrimal ducts have no drainage. No lid lag or nystagmus. Eyelids and eyelashes are evenly distributed."

How do you assess the mouth?

Use a penlight and tongue depressor. Inspect the lips, gums, oral mucosa, tongue, palate, and pharynx.

What instructions should you give during the mouth assessment?

"Stick your tongue to the roof of your mouth." "Stick your tongue out." "Say 'Ah.'" "Please cough." "Please swallow."

What taste question should you ask?

"Have you noticed any changes in your sense of taste recently?"

What should you say during the mouth assessment?

"Lips are moist, clean, and intact. Oral mucosa, buccal mucosa, gums, palate, and tongue are pink and moist. Tongue is midline. Pharynx is pink with no swelling or exudate. Teeth are white and present. No lesions, ulcers, or swelling. Speech is clear. Patient coughs and swallows appropriately. Taste has remained at baseline."

How do you begin the respiratory assessment?

Inspect the chest while asking if the patient has chest pain or shortness of breath.

What should you inspect during the respiratory assessment?

Chest symmetry, respiratory effort, accessory muscle use, retractions, respiratory rate, rhythm, and depth.

How do you auscultate the lungs?

Use the diaphragm of the stethoscope. Listen to 12 anterior and 14 posterior lung fields while the patient takes slow deep breaths through the mouth.

What should you say during the respiratory assessment?

"Thorax is symmetric with good expansion. No retractions or accessory muscle use. Respiratory effort is normal. Respirations are regular in rate, rhythm, and depth. No shortness of breath. Lungs are clear to auscultation anteriorly and posteriorly. No adventitious lung sounds."

How should the patient be positioned for the cardiac assessment?

Raise the head of the bed to approximately 30 degrees with the patient supine.

How do you inspect the precordium?

Use a penlight to inspect for visible pulsations.

What should you say after inspecting the precordium?

"No pulsations noted."

How do you auscultate the heart?

Auscultate all valve areas using the diaphragm first, then repeat with the bell: Aortic, Pulmonic, Erb's Point, Tricuspid, and Mitral.

What should you say during the cardiac assessment?

“Patient carotid pulse is plus 2 bilaterally, with no carotid bruits noted, no JVD distention noted bilaterally, no pulsations, heaves, lifts noted bilaterally of the precordium on exam.

Verbalize during exam that if we did hear a murmur we would put on left lateral side or have pt sit forward and lean

Patient apical pulse is 74, and rate and rhythm is regularly regular, no murmurs were noted. “

How do you assess peripheral vascular status?

Palpate all peripheral pulses bilaterally and assess for edema.

What should you say during the peripheral vascular assessment?

"All pulses are +2 and equal bilaterally. No edema present."

How should the patient be positioned for the abdominal assessment?

Patient should be supine with the bed flat and knees slightly bent.

What is the correct order of the abdominal assessment?

Inspect → Auscultate → Palpate.

How do you auscultate the abdomen?

Use the diaphragm. Begin in the right lower quadrant and proceed clockwise, listening for 30–60 seconds in each quadrant.

What should you say during the abdominal assessment?

"Abdomen is flat, symmetrical, with no bulging or distention. Skin color is appropriate with no scars, rashes, ecchymosis, striae, or pulsations. Active bowel sounds are present in all four quadrants. Abdomen is soft, nontender, and nondistended."

How do you assess the musculoskeletal system?

Inspect and palpate the shoulders, elbows, hips, knees, and ankles. Assess range of motion of elbows and knees. Test grip, biceps, triceps, and ankle strength.

What should you say during the musculoskeletal assessment?

"No deformities, swelling, nodules, or redness. Muscle bulk is appropriate. No tenderness, crepitus, or warmth. Active ROM is complete. Grip, biceps, triceps, and ankle strength are equal bilaterally."

How do you assess the neurological system?

Inspect posture and movement, assess for tremors, test biceps and patellar reflexes, and assess light touch with a cotton ball.

What should you say during the neurological assessment?

"No abnormal posture or body movements. No tremors. Biceps and patellar reflexes are +2 bilaterally. Light touch is intact bilaterally. I would assess pain sensation if the patient could not detect light touch."

How do you conclude the assessment?

"That concludes my assessment. I will document my findings and notify the provider. I will return with an update on the plan of care. Do you have any questions before I leave?"

What should you do before leaving the room?

Lower the bed, raise the side rails, perform hand hygiene, and provide privacy before leaving.