HEAD TO TOE ASSESSMENT

First step

Introduce yourself

perform hand hygiene

identify the patient with name and DOB

explain the procedure

Pain Assessment

Do you have any allergies? Are you experiencing any pain?

First Eval

Vital signs- take temperature

pulse

respirations

blood pressure

oxygen saturation

Second Eval

General appearance- Consciousness

posture

facial expression

Third Eval

Skin and nails- skin color (appropriate for race)

temperature of skin, skin texture (smooth?)

note any lesions

skin turgor

capillary refill

angle of nail bed

Fourth Eval

Examine Head- Note the size and shape

hair color and distribution

inspect the scalp

describe the hair texture

Fifth Eval

Examine eyes- inspect eyelids and eyebrows, inspect and describe the conjunctiva (clear color), inspect and describe sclera (white)

extraocular movements (cranial nerves 3,4,6)- draw a star or H pattern.

pupillary response (cranial nerve 2 and 3), shine light and then test the consensual response

Sixth Eval

Examine ears- Inspect auricle (outside of ear) and tragus (next to cheek)

palpate the auricle and mastoid bone (behind the ear)

test cranial nerve 8 (whisper test)

Seventh Eval

Nose, nostrils, and septum- inspect nose, palpate nasal patency (checking the airway- feel the bridge and soft tissue)

cranial nerve (1) sense of smell (alcohol prep pad under nose with eyes closed)

Eight Eval

Examine sinuses- frontal (above eyebrows), maxillary (next to nose)

Ninth Eval

Mouth and Pharynx- inspect lips, tongue, teeth, gums, mucous membranes, frenulum, pharynx.

Ask if they have tonsils and then inspect and grade tonsils (grade 1)

test cranial nerve 9 glosso (swallow and taste)

10 vagus (check uvula "say ahhh") and can use tongue depressor

Tenth Eval

Examine Face- facial symmetry, skin color, texture and condition

cranial nerve 5 motor- trigeminal: open mouth and clench while palpating

cranial nerve 5 sensory- cotton ball on face, have them note when they feel it

canial nerve 7 motor- facial

11th Eval

Neck- strength look right left back and forward with resistance, range of motion flex (chin to chest), extend (look straight), hyperextend (lean head back), lateral rotation (ears to shoulder)

cranial nerve 11- spinal accessory, shrug shoulders with resistance

palpate carotid (one at a time)

auscultate carotid (bell side of stethoscope)

12th

Anterior thorax and heart sounds-- inspect for respiratory pattern and effort, are they using accessory muscles, shape and configuration, chest symmetry, AP/transverse ratio (1:2), inspect lifts/heaves/pulsations, palpate for tenderness or thrills

auscultate apical pulse (rate and rhythm)

heart sounds with diaphragm and then with bell

anterior breath sounds

13th

Posterior thorax- note any deformities, inspect for symmetry, palpate for tenderness

listen to breath sounds (note clear sounds)

14th

Abdomen- inspect contour (flat), symmetry, skin condition, note any pulsations

Auscultate 4 quadrants (clockwise) and then again with bell for bruits

palpate once

palpate again deeply

assess rebound tenderness (RLQ)

15th

Upper extremities- inspect and palpate shoulders

upper arm strength (push and pull)

palpate brachial pulse

palpate radial pulse

handgrip (squeeze hands)

assess sensation (sharp and dull)

assess proprioception (finger up and down)

16th

Lower extremities- inspect and palpate hip joints

hip range of motion (flex bring leg up, extend bring leg down, abduct (away from midline), adduct (towards midline), internal and external rotation

inspect and palpate knees

range of motion- bend and extend knees

lower leg muscle strength (raise and lower with resistance)

inspect and palpate ankles

ankle range of motion (toes to nose, point toes towards ground, inversion, and exversion)

skin color and condition of feet

palpate foot temp

palpate posterior tibial pulse (above heel, outside of leg)

palpate dorsalis pedis pulse (between big toe and second toe, middle of foot)

assess sensation (sharp and dull)

assess proprioception (toe up and down)

FInal step

hand hygiene