Head to Toe Assessment Guide

1. Vital Signs

• Completes all five vital signs with a numeric pain score.

2. Integumentary

• Inspects and palpates skin on chest, back, arms, and legs for:

  • color

  • temperature

  • lesions

  • skin turgor (hand or sternum)

  • deformities

3. HEENOT and Lymph Nodes

• HEENOT stands for head, eyes, ears, nose, oral cavity/throat, and lymph nodes; thorough assessment of these areas.

• HEAD: Inspects and palpates the head for:

  • position

  • skull size

  • shape

  • symmetry

  • hair texture and pattern

  • infestations

  • tenderness

• FACE: Inspects for color, lesions, shape, symmetry at rest and with movement/expression.

• EYES: Inspects surrounding eye structures including:

  • eyebrows

  • orbits for edema

  • eyelids for tremors

  • inability to fully close or open

  • eyelash entropion or ectropion

  • styes or crusting

  • lower conjunctivae for color, texture

  • cornea for clarity

• EARS: Inspects and palpates ears for:

  • size

  • shape

  • symmetry

  • color

  • nodules

  • tenderness

  • auditory canal for discharge

• NOSE: Inspects nose for deviation; palpates bridge and soft tissue for tenderness, masses, or displacement of cartilage or bone.

• ORAL CAVITY/THROAT: Inspects lips, buccal mucosa, and gums for:

  • color

  • symmetry

  • edema

  • lesions

  • Teeth: noting wear, notches, caries, and loose or missing teeth

• LYMPH NODES: Inspects and palpates:

  • occipital

  • pre/post-auricular

  • tonsillar

  • submandibular

  • submental

  • anterior/posterior cervical

  • supraclavicular

4. Cardiovascular

• Auscultates all five heart sounds with the diaphragm for S1 and S2 sounds. Maintains skin contact.

• Inspects upper extremities for capillary refill.

• Inspects lower extremities for edema from +1 to +4 and capillary refill.

• Assesses dorsalis pedis pulses.

• Note: Edema scale expressed as +1 to +4.

5. Respiratory

• Assesses breathing pattern/effort and chest expansion.

• Auscultates anterior, posterior and lateral breath sounds.

6. Abdominal

• Inspects shape, skin, and pulsations.

• Auscultates all quadrants and verbalizes hypoactive, normoactive, hyperactive findings.

• Lightly palpates abdomen and asks about tenderness.

• Maintains skin contact.

7. Neurological

• Assesses cranial nerves (CN III–XII) as per rubric guidelines.

• Assesses Patellar reflexes on a 0–4 scale.

• Performs one accuracy of movement test and one rapid alternating movement test.

• Assesses Romberg sign.

• Observes gait for symmetry and rhythm.

• Assesses cranial nerves including full name or number; CN I and II assessment deferred.

• CN III (Oculomotor): PERRLA and EOMs.

• CN IV (Trochlear): EOMs.

• CN V (Trigeminal): Light touch to forehead, cheeks, and jaw bilaterally. Clench teeth. Defer corneal sensation.

• CN VI (Abducens): EOMs.

• CN VII (Facial): Raise eyebrows, close eyes tightly, smile, frown, and puff out cheeks. Defer testing taste.

• CN VIII (Acoustic): Finger rub or 6 whispered words bilaterally.

• CN IX (Glossopharyngeal): Swallow ability. Defer testing taste. Defer gag reflex.

• CN X (Vagus): Assesses for speech and hoarseness (patient phonates “Ahh”).

• CN XI (Accessory): Assesses shoulder shrug against resistance and turning head to each side against resistance.

• CN XII (Hypoglossal): Protrusion of tongue and movement up/down and side to side.

8. Musculoskeletal

• Verbally assesses for pain and limited mobility.

• Assesses cervical ROM, upper-extremity ROM, upper-extremity strength, lower-extremity ROM, and lower-extremity strength per rubric guidelines.

• Inspects back alignment and contour for lordosis, kyphosis, and scoliosis.