Head-to-Toe Assessment Notes
Head-to-Toe Assessment Guidelines
Introduction to Assessment
Greeting and Introduction:
Approach the patient respectfully.
Say: "Hi, my name is [Your Name]. I am going to be your student nurse today."
Purpose: Explain the purpose of visit - conducting an assessment.
Privacy and Hygiene:
Ensure privacy before proceeding.
Complete hand hygiene before assessment.
Patient Identification and Orientation
Ask for Patient Identification:
Request full name and date of birth from the patient.
Orientation Check:
Questions to ask:
"Do you know where we are today?"
"What’s today’s date?"
"Why are we here today?"
Document Patient's Alertness and Orientation:
Say: "Patient is alert and oriented times 4 (to person, place, time, and situation)."
General Observation
Initial Assessment:
Observe the patient for any signs of distress or deformities.
Check skin color, clothing, mood, and emotional expression.
Document Findings:
Say: "Patient appears stated age, in no apparent distress. No gross deformities noted. Skin color is congruent with patient’s ethnicity. Mood is congruent with patient's affect."
Head Examination
Symmetry of the Head:
Inspect head for overall symmetry.
Say: "Head is normocephalic. Facial features appear symmetric."
Check for Lice and Swelling:
Inspect hair, looking for signs of lice or swelling.
Cranial Nerve Assessment:
Ask the patient to smile and raise eyebrows.
Say: "Cranial Nerve 7 intact."
Ear Examination
Inspect Ears:
Look for redness, swelling, or discharge.
Palpate:
Palpate the helix, auricle, and tragus.
Pain Assessment:
Ask if there is any pain or tenderness present.
Nasal Check:
Assess for symmetry, polyps, discharge, or deviated septum.
Nares Functionality Test:
Ask patient to close one nostril and breathe in and out.
Repeat on the other side.
Document Findings:
Say: "Nares are patent."
Eye Examination
Inspect Sclera and Conjunctiva:
Pull eyelids gently down.
Document: "Conjunctiva pink and moist; sclera white."
Pupil Assessment:
Check for response to light and accommodation.
Say: "PERRLA (Pupils equal, reactive to light and accommodation)."
Cardinal Gazes:
Have patient follow pen light through six cardinal gazes.
Nystagmus Check:
Observe for any uncontrolled shaking of the eyes (nystagmus).
Document Findings:
Say: "Cranial Nerves 3, 4, and 6 intact; no nystagmus noted."
Oral Examination
Inspect Oral Cavity:
Ask patient to open mouth, inspect lips, buccal membranes, teeth, tongue, hard and soft palate.
Document Findings:
Say: "Lips and buccal membrane are pink and moist; no erythema, swelling, or dental caries."
Gag Reflex Test:
Elicit a gag reflex by placing a tongue blade gently at the back of the throat.
Document: "CN9 and 12 are intact."
Neck and Lymph Nodes
Palpation of Lymph Nodes:
Inspect post-auricular, submandibular, submental, cervical, and supraclavicular areas.
Say: "No palpable lymph nodes."
Trachea Inspection:
Verify that the trachea is midline.
Carotid Artery Palpation:
Palpate carotid arteries individually.
Document: "Carotids are +2 bilaterally."
Jugular Venous Distention (JVD):
Position patient at 45 degrees and check for distention while turning head side to side.
Document: "No JVD noted."
Chest and Respiratory Assessment
Chest Inspection:
Compare A/P (anteroposterior) diameter to transverse diameter.
Document: "No scars; hair distributed symmetrically; no tattoos; A/P is less than transverse diameter; no pulsations or thrills noted."
Lung Auscultation:
Listen to anterior lung fields from supraclavicular to about 7th rib, lateral to 8th rib, and posterior from C7-T12.
As patient takes deep breaths in and out, document: "No adventitious sounds heard; lungs clear to auscultation in all lung fields."
Heart Auscultation:
Listen to heart valves:
Aortic: 2nd intercostal space right of sternum
Pulmonic: 2nd intercostal space left of sternum
Erb's point: 3rd intercostal space left of sternum
Tricuspid: 4th intercostal space left of sternum
Mitral: 5th intercostal space midclavicular line.
Document: "If taking an apical pulse, I would listen for a full minute to count the heart rate."
Assessment of Heart Sounds:
Listen for murmurs with the bell of the stethoscope.
Document findings: "S1, S2 auscultated; regular rate and rhythm; no murmurs detected."
Abdominal Assessment
Inspect Abdomen:
Look for scars, striae, flat abdomen, and pulsations.
Document: "No scars; abdomen flat; no pulsations noted."
Bowel Sounds Listening:
Start in each quadrant:
RUQ, LUQ, LLQ, RLQ.
Document: "Listen for 5-30 gurgles or clicks for normoactive bowel sounds; if absent, listen for a full two minutes before documenting."
Lower Extremities Assessment
Skin Inspection:
Check temperature and symmetry.
Document: "Skin congruent with ethnicity; no pallor; warm to touch; upper extremities symmetrical."
Muscle Strength Test:
Flex elbows and wrists, checking strength through resistance.
Document: "Full ROM, muscle strength 5/5."
Pulse Check:
Assess brachial and radial pulses bilaterally.
Document: "Brachial and radial pulses +2 bilaterally."
Capillary Refill:
Check for capillary refill time in fingers.
Document: "Capillary refill less than 3 seconds."
Skin Integrity and Mobility Assessment
Skin Breakdown Check:
Assess sacrum and skin integrity for pressure sores.
Perineal Area Integrity Assessment:
Check for breakdown or irritation in the perineal area.
Full Mobility Assessment
Leg Examination:
Inspect skin temperature and symmetry in lower extremities.
Document: "No signs of dirt; skin congruent with ethnicity; no pallor; warm to touch."
Muscle Strength and Movement:
Check knee flexion bilaterally and push-pull tests against resistance.
Document: "Full ROM, muscle strength 5 of 5."
Vascular Assessment:
Assess femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally.
Document: "Femoral, popliteal, posterior tibial, and dorsalis pedal pulses +2 bilaterally."
Capillary Refill Check for Toes:
Document: "Capillary refill less than 3 seconds."
Final Assessment and Patient Mobility
Patient Mobility Test:
Ask the patient to sit up on the side of the bed and check for dizziness or weakness before standing.
Observe as they walk, ensuring safety.
Document Mobility Findings:
Document: "Patient ambulates with a smooth gait without the need for assistive devices."
Conclusion of Assessment
Final Notes:
Review the 5 P's with the patient.
Communicate that the assessment is complete.
Say: "Hand hygiene completed. If you need anything, call someone will be around for rounds in about an hour."
Introduction to Assessment
Greeting and introduction are critical when beginning the assessment. You should approach the patient respectfully and say: "Hi, my name is [Your Name]. I am going to be your student nurse today." It's important to explain the purpose of your visit, which is to conduct an assessment. Ensure privacy before proceeding, and complete hand hygiene before you begin the assessment.
Patient Identification and Orientation
Start by requesting patient identification, asking for their full name and date of birth. It's also essential to verify orientation by asking questions like: "Do you know where we are today?" "What’s today’s date?" and "Why are we here today?" Document the patient's alertness and orientation by stating, "Patient is alert and oriented times 4 (to person, place, time, and situation)."
General Observation
During the initial assessment, observe the patient for any signs of distress or deformities. Check their skin color, clothing, mood, and emotional expression. Document your findings by stating, "Patient appears stated age, in no apparent distress. No gross deformities noted. Skin color is congruent with patient’s ethnicity. Mood is congruent with patient's affect."
Head Examination
Inspect the head for overall symmetry and say, "Head is normocephalic. Facial features appear symmetric." Check the hair for signs of lice or swelling and conduct a cranial nerve assessment by asking the patient to smile and raise their eyebrows, stating, "Cranial Nerve 7 intact."
Ear Examination
Inspect the ears for redness, swelling, or discharge. Palpate the helix, auricle, and tragus. Assess for any pain or tenderness present. Next, check the nose for symmetry, polyps, discharge, or a deviated septum. To test nares functionality, ask the patient to close one nostril and breathe in and out, then repeat on the other side, documenting: "Nares are patent."
Eye Examination
During the eye examination, pull the eyelids gently down to inspect the sclera and conjunctiva. Document your findings by stating, "Conjunctiva pink and moist; sclera white." Conduct a pupil assessment by checking their response to light and accommodation, stating: "PERRLA (Pupils equal, reactive to light and accommodation)." Then, have the patient follow a penlight through six cardinal gazes and check for nystagmus, documenting: "Cranial Nerves 3, 4, and 6 intact; no nystagmus noted."
Oral Examination
Ask the patient to open their mouth and inspect their lips, buccal membranes, teeth, tongue, and hard and soft palate. Document your findings by stating, "Lips and buccal membrane are pink and moist; no erythema, swelling, or dental caries." Test the gag reflex by placing a tongue blade gently at the back of the throat, documenting: "CN9 and 12 are intact."
Neck and Lymph Nodes
Palpate lymph nodes in the post-auricular, submandibular, submental, cervical, and supraclavicular areas, stating: "No palpable lymph nodes." Check the trachea for midline positioning. Palpate carotid arteries individually, documenting: "Carotids are +2 bilaterally." To assess for jugular venous distention (JVD), position the patient at 45 degrees and check for distention while turning the head side to side, documenting: "No JVD noted."
Chest and Respiratory Assessment
For chest inspection, compare the anteroposterior diameter to the transverse diameter, stating: "No scars; hair distributed symmetrically; no tattoos; A/P is less than transverse diameter; no pulsations or thrills noted." During lung auscultation, listen to anterior lung fields from the supraclavicular area to about the 7th rib, laterally to the 8th rib, and posteriorly from C7 to T12 as the patient takes deep breaths, documenting: "No adventitious sounds heard; lungs clear to auscultation in all lung fields." For heart auscultation, listen to the heart valves at specified locations and document: "If taking an apical pulse, I would listen for a full minute to count the heart rate." When assessing heart sounds, listen for murmurs with the bell of the stethoscope, documenting: "S1, S2 auscultated; regular rate and rhythm; no murmurs detected."
Abdominal Assessment
Inspect the abdomen for scars, striae, flatness, and pulsations, documenting: "No scars; abdomen flat; no pulsations noted." For bowel sounds, listen in each quadrant (RUQ, LUQ, LLQ, RLQ), stating: "Listen for 5-30 gurgles or clicks for normoactive bowel sounds; if absent, listen for a full two minutes before documenting."
Lower Extremities Assessment
Check the skin of lower extremities for temperature and symmetry, documenting: "Skin congruent with ethnicity; no pallor; warm to touch; upper extremities symmetrical." Test muscle strength by flexing elbows and wrists against resistance, stating: "Full ROM, muscle strength 5/5." Assess brachial and radial pulses bilaterally, document: "Brachial and radial pulses +2 bilaterally." Lastly, check for capillary refill time in fingers, documenting: "Capillary refill less than 3 seconds."
Skin Integrity and Mobility Assessment
Assess the sacrum and skin integrity for pressure sores. Check the perineal area for breakdown or irritation. In performing a full mobility assessment, inspect skin temperature and symmetry in lower extremities, documenting: "No signs of dirt; skin congruent with ethnicity; no pallor; warm to touch." Test muscle strength and movement through knee flexion bilaterally and push-pull tests against resistance, documenting: "Full ROM, muscle strength 5 of 5." Conduct a vascular assessment by assessing femoral, popliteal, posterior tibial, and dorsalis pedis pulses bilaterally, stating: "Femoral, popliteal, posterior tibial, and dorsalis pedal pulses +2 bilaterally." Finally, check capillary refill for toes, documenting: "Capillary refill less than 3 seconds."
Final Assessment and Patient Mobility
For the patient mobility test, ask the patient to sit up on the side of the bed and check for dizziness or weakness before standing. Observe them as they walk to ensure safety. Document mobility findings by stating: "Patient ambulates with a smooth gait without the need for assistive devices."
Conclusion of Assessment
In your final notes, review the 5 P's with the patient, communicate that the assessment is complete and say: "Hand hygiene completed. If you need anything, call someone will be around for rounds in about an hour."