Head to Toe Assessment Form

“Hi my name is _______. I will be your student nurse today. I will be performing a head to toe assessment, will that be ok? Can I please check your wristband? Can you please state your name and date of birth for me? Do you know where you are? Who is the president of the US?” INTEGUMENTARY: NAILS: SKIN: INSPECTION: Upper/Lower (Color, Pigmentation, Lesions, Texture, Edema): “skin tone is even throughout upper and lower extremities, no signs of cyanosis, no lesions, smooth PALPATION: *feel pt extremities while verbalizing* (Temp., moisture, edema, turgor) Upper: “skin warm to touch, dry, no edema” Lower: “skin warm to touch, dry, no edema” *pinch skin at hand* “pt has good skin turgor, no tenting” NAILS: INSPECT (Shape/Contour/Color/Consistency): “Shape is slightly convex, nails are clear with pink undertones, smooth no rigidity, or swelling” HEAD: FACE: EARS: “Now I am going to assess your head, face, and ears” HEAD: INSPECT: (head/scalp, hair) “Head is round and symmetric, hair is evenly distributed, scalp is clear” PALPATION: (head/scalp, hair) “I don’t feel any bumps or lesions, no pain or tenderness” FACE: INSPECT: “Eyes are symmetric, nose is midline” (facial expressions- CN 7) *ask pt to open/close eyes, smile, frown* “No facial weakness, movements are smooth and coordinated” PALPATION: Sinuses (Frontal and maxillary) “No pain or tenderness” (CN 5- Trigeminal) *ask pt if they feel certain sensation* “Pt feels touch” *palpate TMJ* “No TMJ displacement, no pain, no crepitus” EARS: INSPECT/PALPATE: (External structures, internal canal, hearing CN 8) “Ears are symmetrical, no redness, no drainage” *move pinna and push on tragus* “Pinna and tragus feel firm, no pain” *whisper test (CN 8)* “Pt has no loss of hearing” EYES: INSPECTION: Eyelids/lashes, sclera, conjunctiva: *use pen light to look into eye* “No eyelid discoloration, lashes are intact. Sclera is white, conjunctiva is pink and moist” *Verbalize schnellen chart* “I would use a schnellen chart to measure visual acuity” “I will be testing CN 3, 4,6” PERRLA “Positive for PERRLA, pupils are equal, round, reactive to light, and accommodate” EOM (6 cardinal gazes)- *wagon wheel method* “EOM intact, parallel tracking of object with both eyes” Cover and uncover Test Red reflex- “Red reflex is present” Direct & consensual response- *ask pt to stare at an object. Shine light by side of cornea and move out, as you move out eye dilates, as you move in eye constricts* “Pt eyes respond to direct and consensual light” NOSE: MOUTH/THROAT: NOSE: INSPECT: (external nose, internal nares, drainage) “Nose is symmetrical, midline, no drainage” PALPATE: (assess patency of nares) *have pt hold one nostril and breathe in, repeat in other nostril* “No obstruction, nares are patent” Verbalize CN 1-olfactory Testing- *ask pt to smell alcohol swab & identify it* MOUTH/THROAT: INSPECT: (lips, teeth, oral mucosa, throat) “Lips are pink, teeth present, gums are pink, tongue is moist, throat is pink” Assess tongue CN 12 (Hypoglossal)- *ask pt to move tongue up/down, side-toside* “CN 12 intact” NECK: Assess uvula/soft palate CN 9, 10 (Glossopharyngeal and vagus)- *ask pt to say “ahh”* “Palate intact, uvula present, positive gag reflex” INSPECT/PALPATE: Lymph nodes (verbalize names AND palpate!)  Preauricular  Post auricular  Occipital  Retropharyngeal (tonsillar)  Submandibular  Submental  Superficial cervical  Deep cervical  Supraclavicular “I will now test CN 11” CN 11 (accessory)- 1. have patient shoulder shrug and put resistance over their shoulder 2. Have pt turn head side to side “5 to 5 muscle strength” Palpate trachea “Trachea is midline, no deviation” Check for JVD (jugular vein distention) “No presence of JVD” PALPATE/ASCULATATE: Carotid pulse & presence of bruits- *palpate pulse bilaterally and auscultate carotid for bruits* “Pulsation +2, no bruits” RESPIRATORY: INSPECTION: Posterior (thoracic cage, respirations) “Scapula’s are symmetrical” Anterior (thoracic cage, respirations) “Chest appears symmetrical, clavicles aligned” “18 breathes per minute” PALPATION: Posterior-Symmetrical Chest Expansion “I’m going to put my hands on your back and pinch to check resp. expansion. Pt has symmetrical chest expansion” PERCUSSION: Posterior- *percuss pt in posterior lung fields* “Resonance is heard through the lung fields” AUSCULTATION: breath sounds Posterior & anterior- Anterior ^ Posterior ^ “Vesicular sounds are heard throughout the lung surfaces, no adventitious sounds” CARDIOVASCULAR: INSPECTION: Chest wall, heaves/lifts, PMI (point of maximum impulse)- “I’m going to inspect your chest for any pulsations and heaves. No visible heaves or pulsations” PALPATION: Heaves/lifts, PMI- *feel for heaves and check apical pulse* “I don’t feel any heaves and apical pulse has a regular rate and rhythm” Capillary refill- *check capillary refill in upper bilateral and lower bilateral extremities by pressing down on finger nail and releasing* “Pt has sufÏcient peripheral perfusion” Check pulses- carotid, radial, dosalis pedis, posterior tibialis “Pulsations +2” AUSCULTATION: Auscultate heart valves S1 and S2: “I’m going to listen to S1 and S2. S1 is heard loudest at the apex and S2 is heard loudest at the base” “Now I am going to auscultate the aortic, pulmonic, erb’s point, tricuspid, and mitral valve” *auscultate and verbalize name* PMI- pulse of maximum impulse “PMI is at the apical pulse, regular rate and rhythm” Left lateral positioning assess S3, S4, Murmurs “Pt does not have and S3, S4 sounds or any murmurs” *****REMEMBER TO KNOW THE PROPER USE OF DIAPGHRAM AND BELL OF STETHASCOPE!!!!!******** ABDOMINAL GENITOURINARY: GU: INQUIRE: (last bm, pain, tenderness, last void) “When was your last bowel movement? Do you feel any pain or tenderness? When was your last void? INSPECTION: Verbalize: skin integrity perineum assessed- “No perineum skin break down” ABDOMEN: INSPECTION:(contour/shape, symmetry, color, pulsations, skin, vascularity, suprapubic distention) “Abdomen is flat, even color, umbilicus is midline, no bulges or pulsations, skin is smooth, no distention” AUSCULTATION: (bowel sounds 4 quadrants, vascular sounds) “Bowel sounds present in each quadrant” *Check for vascular sounds over the aorta, renal arteries, iliac and femoral arteries* “No bruits heard” PERCUSSION: percuss 4 quadrants “I am going to percuss the 4 quadrants. Tympany is heard over the gastric bubble” PALPATION: 4 quadrants light and deep “No pain or tenderness” Suprapubic distention “no distention” MUSCULOSKELETAL: INSPECTION/PALPATION: INSPECT: joint and skin characteristics- “Joints are symmetrical and equal in size, skin color is evenly distributed, no swelling” Upper Extremities: Range of Motion (ROM):  Active  Against resistance  Abduction  Adduction  Flexion  Extension  Elevation  Depression  Hand grasp Lower Extremities: Range of Motion (ROM):  Active  Against resistance  Abductions  Adduction  Flexion  Extension  Elevation  Depression NEUROLOGICAL INQUIRY: (person, place, time) – did this at beginning when you asked pt for wristband, where they are, etc. but you could just repeat it “Can I please see your wristband? Can you tell me your name and DOB? Do you know where you are? Who is the president of the US?” INSPECTION: Mental status/loc: “Pt is awake, alert, oriented x3” Graphesthesia: *tell pt to close eyes and draw a number 8 on their hand and have them identify it* Stereogenesis: *have pt close eyes ad place an object on their hands and have them identify it* CN 1-12 Testing (should’ve been done throughout exam or system)