Head-to-Toe Assessment

Head-to-Toe Assessment Study Guide

Foundational Principles and Initial Steps

• Privacy and Safety Prioritization

  • Always ensure patient privacy. The patient should be in a gown and under bed covers.

  • Maintain patient safety throughout the assessment.

  • Skin Contact for Accuracy:

    • Stethoscope must be placed directly on the skin for accurate auscultation of heart, lungs, and bowels.

    • Pulses must be palpated skin-to-skin.

    • Skin can be visualized and palpated through clothing as necessary.

• The Seven Cardinals (Can be performed in any order):

  1. Identify self to the patient and confirm identity using $2$ patient identifiers (name and date of birth).

  2. Review the patient's chart and any current orders.

  3. Gather all necessary equipment.

  4. Perform hand hygiene (wash hands).

  5. Ensure patient privacy.

  6. Fully explain the procedure to the patient.

  7. Check for any patient allergies.

• Pain Assessment:

  • Ask the patient about any current pain.

  • Have the patient rate their pain on a numerical scale from $0-10$, where $0$ is no pain and $10$ is the worst possible pain.

  • Verbalize your assessment of the patient's pain.

• Nursing Questions and Medication History:

  • Inquire about the patient's general feeling or well-being.

  • Ask if the patient has any specific concerns.

  • Determine if the patient has any chronic illnesses.

  • Obtain a comprehensive medication history, including prescription medications, over-the-counter (OTC) drugs, and herbal products.

• Orientation Assessment:

  • (Name and DOB were already confirmed during the Seven Cardinals).

  • Ask the patient: "Where are you?"

  • Ask the patient: "What day is it? What is the approximate time?"

  • Ask the patient: "Why are you here today?"

  • Verbalize that the patient is "alert and oriented times four" if all questions are answered correctly.

Head and Face Assessment

• Head and Face Examination:

  • Inspect the facial skin for color, lesions, and overall condition.

  • Observe facial symmetry.

  • Assess cranial nerve function by having the patient perform facial movements: smile, frown, stick out tongue, move tongue up and down, and puff out cheeks.

  • Palpate the scalp and head for tenderness, lumps, or lesions.

  • Verbalize Findings: Confirm face and head symmetry, non-tender, skin clear and intact. (Optional: Note if the patient hears normal conversation).

• Mouth Examination:

  • Using a penlight, inspect the inside of the mouth.

  • Verbalize Findings: Mucous membranes are intact, moist, and pink.

• Eye Assessment - PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation):

  • Pupil Size: Measure the size of each pupil. This must be done before checking light reaction.

  • Light Reaction: Check each pupil individually for direct reaction to light.

  • Consensual Reaction: Observe the opposite pupil for consensual reaction when light is shined into the first eye.

  • Accommodation: Instruct the patient to look at a distant wall, then shift focus to the end of a penlight held close to their nose. Pupils should constrict when focusing on the penlight.

  • Verbalize Findings: State pupil size and confirm "Pupils equal, round, reactive to light and accommodation: PERRLA."

• Eye Assessment - Six Cardinal Fields of Gaze:

  • Position a penlight approximately $12-18$ inches from the patient's face.

  • Instruct the patient to follow the penlight with their eyes only, without moving their head.

  • Slowly move the penlight through the six fields of gaze:

    • Right upper, lateral, lower (with a pause in the middle each time).

    • Left upper, lateral, lower (with a pause in the middle each time).

  • Observe for any abnormal or asymmetrical eye movements (e.g., nystagmus).

  • Verbalize Findings: Confirm "Six cardinal fields of gaze intact."

• Conjunctiva and Sclera Examination:

  • Have the patient gently pull down their lower eyelids.

  • Verbalize Findings: Confirm conjunctiva is pink, moist, and intact; sclera is clear and white.

Neck Assessment

• Jugular Vein Distention (JVD) Assessment:

  • Position the head of the bed (HOB) at $45$ degrees.

  • Remove the patient's pillow.

  • Ask the patient to turn their head to the left, then to the right.

  • Verbalize Findings: Confirm "No JVD present."

• Carotid Pulse Palpation:

  • Palpate each carotid pulse one at a time directly on the skin to prevent compromising cerebral blood flow.

  • Rate the strength of each pulse on a scale of $0-4+$ (e.g., $0$ = absent, $1+$ = weak, $2+$ = normal, $3+$ = strong, $4+$ = bounding).

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ bilaterally."

Posterior Chest and Lung Assessment

• Posterior Chest Inspection and Palpation:

  • Assist the patient to sit on the side of the bed, ensuring privacy and safety.

  • Inspect the skin of the back: Verbalize "Skin clear and intact."

  • Lightly palpate the back: Verbalize "Warm, soft, non-tender."

  • Tactile Fremitus: Ask the patient to say "99" three times while you palpate the back symmetrically. Verbalize "Fremitus vibrations felt throughout."

  • Chest Excursion: Place your hands on the lower thoracic area of the patient's back and ask them to breathe deeply. Observe the symmetrical movement of your thumbs. Verbalize "Chest excursion symmetrical."

• Posterior Lung Auscultation:

  • Introduction to Patient: "I will listen to lung sounds in $10$ places. The first $2$ are vesicular, the next $4$ are bronchovesicular, and the last $4$ are vesicular."

  • Patient Instructions: Instruct the patient, "Every time you feel my stethoscope, please take a deep breath in and out. If you feel dizzy or lightheaded, let me know by raising your right hand, and we can take a break."

  • Procedure:

    • Must listen to both inhale and exhale at each spot.

    • Compare findings from the left side to the right side symmetrically.

    • Ensure the stethoscope is directly on the skin every time.

  • Verbalize Findings: "Lung sounds clear to auscultation."

• Lateral Lung Auscultation:

  • Introduction to Patient: "I will listen to lung sounds in $7$ places, starting on the right and ending on the right. All of these sounds are vesicular."

  • Patient Instructions: Similar to posterior lung auscultation, instruct the patient to take deep breaths and to signal if dizzy or lightheaded.

  • Procedure:

    • Must listen to both inhale and exhale at each spot.

    • Compare findings from left to right.

    • Ensure the stethoscope is directly on the skin every time.

  • Verbalize Findings: "Lung sounds clear to auscultation."

• Posterior Skin Check:

  • Ask the patient to lie back in bed and roll to one side for a comprehensive posterior skin check, examining all posterior skin from head to toe.

  • Verbalize Findings: "Skin clear and intact."

Anterior Chest and Lung Assessment

• Anterior Chest Inspection and Palpation:

  • Inspect the skin of the anterior chest: Verbalize "Skin clear and intact."

  • Lightly palpate the upper chest: Verbalize "Warm, soft, non-tender."

  • Skin Turgor: Check skin turgor on the upper chest.

  • Verbalize Findings: Note if "skin returns immediately" or "less than $1$ second," indicating good hydration.

• Anterior Lung Auscultation:

  • Introduction to Patient: "I will listen to lung sounds in $8$ places. The first $2$ are bronchial, the next $4$ are bronchovesicular, and the last $2$ are vesicular."

  • Patient Instructions: Similar to posterior (deep breaths, signal if dizzy).

  • Procedure:

    • Must listen to both inhale and exhale at each spot.

    • Compare findings from left to right.

    • Ensure the stethoscope is directly on the skin every time.

  • Verbalize Findings: "Lung sounds clear to auscultation."

Heart Assessment

• Heart Auscultation and Apical Pulse:

  • Introduction to Patient: "I will listen to $4$ main heart sounds:

    • The aortic valve: located at the $2$nd intercostal space, right sternal border (an $S2$ sound).

    • The pulmonic valve: located at the $2$nd intercostal space, left sternal border (also an $S2$ sound).

    • The tricuspid valve: located at the $4$th intercostal space, left sternal border (an $S1$ sound).

    • The mitral valve: located at the $5$th intercostal space, left midclavicular line (an $S1$ sound), where I will stay for $1$ minute to listen to the apical pulse."

  • Procedure:

    • Palpate and auscultate each heart sound location for $5-10$ seconds.

    • Listen for a full minute at the mitral valve for the apical pulse.

  • Verbalize Findings: Confirm "$S1$ and $S2$ auscultated and apical pulse is [rate]."

Upper Extremity Assessment

• Upper Extremity Inspection and Palpation:

  • Inspect the skin of the anterior and posterior upper extremities: Verbalize "Skin clear and intact."

  • Perform light palpation of the upper extremities: Verbalize "Warm, soft, and non-tender."

• Brachial Pulse Palpation:

  • Palpate each brachial pulse one at a time or simultaneously, directly on the skin.

  • Rate strength $0-4+$.

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ equal or bilaterally."

• Radial Pulse Palpation:

  • Palpate both radial pulses simultaneously, directly on the skin.

  • Count the radial pulse on one side for $30$ seconds (or $15$ seconds and multiply by $4$).

  • Rate strength $0-4+$ equal.

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ equal. Radial pulse is [rate]."

• Upper Extremity Capillary Refill:

  • Check capillary refill on all $10$ fingernails or finger beds (if wearing polish, check the finger beds).

  • Verbalize Findings: "Capillary refill less than $2$ seconds for all $10$ fingers."

• Upper Extremity Strength Assessment:

  • Assess muscle strength by having the patient perform push, pull, and squeeze actions against resistance on both upper extremities.

  • Verbalize Findings: "Strength $5$ out of $5$ equal."

Gastrointestinal/Genitourinary (GI/GU) Assessment

• GI/GU Nursing Questions:

  • Ask about the patient's last bowel movement, noting any diarrhea or constipation.

  • Ask about the patient's last urination, including color, presence of burning, or odor.

  • Ask female patients about their last menstrual cycle.

  • Inquire if the patient needs to urinate before the abdominal assessment to ensure comfort and accurate findings.

• Abdomen Inspection:

  • Inspect the abdominal skin: Verbalize "Skin clear and intact."

  • Inspect the abdomen's shape: Verbalize "Flat or rounded abdomen."

  • Ensure the HOB is at $20$ degrees or less for this part of the assessment.

• Abdomen Auscultation:

  • Auscultate each of the four abdominal quadrants for at least $15$ seconds.

  • Verbalize Findings: "Normoactive bowel sounds."

• Abdominal Palpation:

  • Maintain HOB at $20$ degrees or less.

  • Have the patient's knees bent to relax abdominal muscles.

  • Perform light palpation across all four quadrants (this may be a one-handed technique).

  • Verbalize Findings: "Warm, soft, non-tender."

Lower Extremity Assessment

• Lower Extremity Inspection and Palpation:

  • Inspect the skin of the anterior and posterior lower extremities: Verbalize "Skin clear and intact."

  • Perform light palpation of the lower extremities: Verbalize "Warm, soft, and non-tender."

• Popliteal Pulse Palpation:

  • Palpate each popliteal pulse one at a time for $5-10$ seconds, directly on the skin.

  • If unable to locate, verbalize that you "will obtain a doppler to verify."

  • Rate strength $0-4+$ bilaterally.

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ bilaterally."

• Posterior Tibialis Pulse Palpation:

  • Palpate both posterior tibialis pulses simultaneously, directly on the skin.

  • Rate strength $0-4+$ equal.

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ equal."

• Dorsalis Pedis Pulse Palpation:

  • Palpate both dorsalis pedis pulses simultaneously, directly on the skin.

  • Rate strength $0-4+$ equal.

  • Verbalize Findings: Confirm "Regular rate and rhythm, $2+$ equal."

• Lower Extremity Capillary Refill:

  • Check capillary refill on all $10$ toenails or toe beds (if wearing polish).

  • Verbalize Findings: "Capillary refill less than $2$ seconds for all $10$ toes."

• Lower Extremity Strength Assessment:

  • Assess muscle strength by having the patient perform push and pull actions against resistance on both lower extremities.

  • Verbalize Findings: "Strength $5$ out of $5$ equal."

Concluding Steps

• Comfort and Privacy:

  • Address the "$4$ P's" for patient comfort: Pain, Potty, Position, and Possessions.

  • Verbalize the patient's current pain rating.

  • Ensure the patient is comfortable before leaving.

  • Continue to provide privacy throughout the entire assessment.

• Safety Measures:

  • Ensure the bed is in its lowest position.

  • Confirm the bed is locked.

  • Raise the appropriate upper side rails.

  • Place the call light within the patient's reach.