Head to Toe Assessment 1

Introduction
o Provide Privacy “Hi my name is Abegail, I will be your nurse
o Introduce yourself today! How are you doing?”
o Explain Reason for Examination “So today I’m going to do a head to toe
o Bladder physical exam on you, it’s going to take a
o Wash hands while so if you need to use the bathroom, now
is the time.”
Patient states she went to the bathroom.
Perform hand hygiene.
Vital Signs
o Verbalize that you are doing Vital Signs, “Now I’m going to do your vitals signs, take
Weight, Height and BMI your height and weight and calculate your
BMI”

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“Before we start with the general survey can

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you remember these three words for me”

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“Snow, Cookies, Rain”

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General Survey

o.
o Observe general appearance of client o Ask for patient’s name “What’s your
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o Assess level of orientation name?”
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o Date of Birth “When is your birthday?”
o Where are you?
o What is the date today?
o

o Who is the president?

aC s

o Ask patient to recall three words

vi y re

Head
o Inspect head
o Palpate Scalp for tenderness
o Inspect Hair for distribution
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o Palpate for temporal artery

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o Palpate the Frontal Sinus, Ethmoid Sinus,

Maxillary Sinus
o Palpate the temporomandibular joint TMJ
o CRANIAL NERVE 5 Trigeminal Nerve
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o Open Jaw (against resistance)

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o Move Jaw side to side

o Palpate Jaws during movement
o Pain and Sensory (Dull/Sharp)

o CRANIAL NERVE 7 Facial Nerve

o Smile
o Raise Eyebrows
o Puff out your cheeks
o Stick out your tongue
o Clench teeth
o Close your eyes really hard

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Eyes
o Inspect Eye Structures
o Eyelids
o Eyebrows
o Sclera
o Pupil
o Iris
o Conjunctiva
o Palpate Lacrimal apparatus
o Palpate Lacrimal duct
o CRANIAL NERVE 2 Optic Nerve o PERRLA
o Snellen Chart - Pupils are Equal, Round and Reactive to
o CRANIAL NERVE 3,4,6 Oculomotor, Light and Accommodation

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Trochlear, Abducens Nerve

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o Accommodation (pupil dilation)

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o Convergence (slowly put penlight

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towards nose)
o Hirschberg Test (assess for

o.
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alignment of the eyes) – place
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light between eyes
o Cardinal field of gaze (H)
o Confrontation (peripheral vision)
wiggle hands
o
aC s

Ears
vi y re

o Inspect the auricle, tragus and lobule

o Palpate auricle, tragus and mastoid
process
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ar stu

o CRANIAL NERVE 8 Acoustic Nerve

o Whisper Test (ice cream baseball
cupcake)
o Weber Test
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o Rinne Test
Th

Nose
o Inspect and palpate the external Nose

o CRANIAL NERVE 1 Olfactory

(Smell) Nerve
o Check for patency
o Ask patient to determine smell

https://www.coursehero.com/file/67021737/Head-to-Toe-Assessment-Finalpdf/
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Mouth
o Inspect Mouth
o Lips
o Teeth
o Buccal Mucosa
o Hard and soft palate
o Tongue
o Under tongue Wharton’s duct
o Palpate the tongue

o CRANIAL NERVE 9 & 10

Glossopharyngeal and Vagus
o Gag reflex
o Stick out tongue

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o Say ahh – uvula rise

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o Swallow

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o CRANIAL NERVE 12 Hypoglossal

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o Tongue strength and symmetry

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o Push tongue against cheek
o CRANIAL NERVE 7 & 9 rs e
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o Taste

Neck
o

o Inspect the Neck

aC s

o Ask patient to swallow water

vi y re

o Palpate trachea
o Palpate thyroid gland

o CRANIAL NERVE 11
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Spinal Accessory Nerve

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o Head rotation
o Push hands against cheek
o Shoulder shrug (with resistance)
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Lymph Nodes
Th

o Palpate and verbalize each name of LN

o Pre auricular
o Post auricular
o Occipital
o Jugulodigastric/Tonsilar
o Submandibular
o Submental
o Superficial Cervical
o Deep cervical chain
o Posterior cervical
o Supraclavicular

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Cardiovascular
o Inspect Jugular venous distention Patient in supine position with head elevated
o Inspect and palpate Carotid pulse at 30-45 º stand on the right side and inspect
o Auscultate Carotid pulse with the bell for pulsations

o Inspect Precordium
o Palpate Precordium

o Auscultate heart sounds with bell and Auscultate in all positions

diaphragm - sitting down and lean forward
o Aortic - Lying down
o Pulmonic - Turn to left lateral position
o Erb’s point Patient in supine position with head elevated
o Tricuspid at 30-45 º stand on the right side and inspect

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o Mitral for pulsations

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Respiratory

o.
o Inspect breathing patterns Inspect the chest wall from the side of the
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o Inspect chest wall shape patient and check for any barrel chest or
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deformities.
o

o Palpate Tactile fremitus palpate and ask patient to say

aC s

o Anterior and posterior thorax ninety nine – vibration should be equal

vi y re

o Crepitus
o Tactile fremitus
§ Ninety-nine
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o Chest expansion
ar stu

o Percuss Resonance
o Anterior and Posterior Thorax
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Th

o Auscultate Auscultate 10 areas

o Lung sounds Bronchophony – ask patient to say ninety
§ Anterior (8 areas) nine while you auscultate – you should hear
§ Posterior (10 areas) muffled sounds
o Bronchophony
§ Ninety-nine
o CVA reflex (in the back palpate kidney)

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Abdomen
o Inspect the abdomen at the foot of the bed o Patient’s position: Supine, hands at their
and from the side side and knees bent feet flat on the table
o Inspect the abdominal aorta and arteries
for pulsations
o Auscultate for Bowel sounds RLQ
clockwise with diaphragm
o Auscultate for Vascular sounds with bell
o Aorta – below xiphoid
o R/L Renal – above umbilicus
o R/L Iliac –below umbilicus
o R/L Femoral
o Percuss Tympanic and Dull

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o Palpate

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o Light

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o Deep

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o Abdominal reflex (stroke above and
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below umbilicus)

Upper Extremities
o

o Inspect for edema

o Inspect nail
aC s
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o Capillary refill

o Palpate for temperature

o Palpate joints (start with clavicles,
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shoulders, biceps, elbow, wrist, arms,

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fingers)
o Palpate Brachial Pulse
o Palpate Radial Pulse
o Palpate hands
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Lower Extremities
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o Inspect for edema

o Inspect nails
o Capillary refill

o Palpate for temperature

o Palpate joints (Palpate quads, knees,
calves
o Palpate popliteal pulse
o Palpate posterior tibial pulse
o Palpate Dorsalis pedis
ASK PATIENT TO STAND

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RANGE OF MOTION
o Spine
o Inspect the spine from the back and from the side
o Palpate spinous process
o ROM
§ Ask patient to touch toes
§ Observe for symmetry of spine
§ Ask patient to bend to the sides
§ Ask patient to lean back
o Upper Extremities
o Shoulders, Arms and Elbow
§ Forward Flex
§ Hyperextension (move arms towards the back)
§ Abduct (Raise arm to the head)

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§ Flex elbows
§ Supination Pronation

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o Wrist
§ Extension/Flexion

o.
§ Radial/Ulnar Deviation
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§ Carpal Tunnel Syndrome
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o Hands and Fingers
§ Spread fingers apart
§ Make a fist
o

§ Bend fingers up and down

aC s

§ Move thumb away from fingers

vi y re

§ Touch the thumb to each fingers

§ Ask patient to squeeze fingers
§ TEST FOR STRENGTH RESISTANCE
o Lower Extremities
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o Hip (SUPINE)
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§ Inspect Hip standing up

§ SUPINE
§ Raise legs extended
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§ Raise bent knees against chest

§ Move legs away from midline
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o Knees
§ Bend
o Ankle
§ Point toes up and down
§ Turn sole out and in
o Feet
§ Spread feet
§ Toes up/Toes down
§ Foot push

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o Strength Test
o Squeeze fingers
o Push and pull against Hand
o In and out against Hand
o Push up and down Wrist
o In and out wrist
o Push and pull elbow
o In and out against elbow
o Push and Pull quad
o In and out quad
o Push and Pull Calves
o Feet up and down
o Evert/ Invert

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Neurological

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o Sensory (Ask patient to close eyes)

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o Sharp and dull

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o Light tough cotton swab

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o Two-point discrimination
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o Position sense (move finger or toes up or down and ask patient)
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o Stereognosis Tactile discrimination (ask patient to determine object on their palm)
o Graphesthesia (write number on their palm)
o Tactile localization (ask patient where you are touching)
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o Vibration sense
aC s
vi y re

o Reflex Testing
o Biceps
o Triceps
o Brachioradialis
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o Patellar
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o Achilles
o Plantar Reflex ( stroke bottom of feet form heel to toe)
o Cerebellar Function
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o Romberg Test
o Hop on one foot
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o Bend down on one knee

o Heel to shin
o Finger to nose
o Finger to finger rapid alternating movements

https://www.coursehero.com/file/67021737/Head-to-Toe-Assessment-Finalpdf/

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