Question

This activity will provide an overview of your initial client assessment. I want you to approach a certain member of a family or housemate and observe and take note on the following:

1. over-all appearance
2. level of consciousness
3. facial features and expressions
4. demeanor and affect
5. Posture
6. Gait
7. Motor activity
8. Speech
9. Skin color and lesion
10. Dress and personal hygiene
11. Skull
12. Face
13. Eye Structures
14. Visual Acuity
15. Ears

Answer 1

Head/Face

1. Check distribution and condition of hair
2. Check scalp for bumps, nits, lesions, etc
3. Palpate skull for tenderness
4. Check for symmetrical facial movements
5. Assess sharp and dull sensation on face

Eyes

1. Assess symmetry
2. Eyebrow and eyelash distribution
3. Check state of conjunctiva
4. Check sclera
5. Assess state of patient’s cornea
6. PERRLA
7. Check the six cardinal positions of the gaze
8. Assess patient vision with Snellen Charts

Ears

1. Inspect and palpate auricle for lesions, tenderness
2. Look inside ear; assess ear discharge and tympanic membrane
3. Tuning fork tests (Weber’s Test, Rinne Test)
4. Assess patient hearing with whisper test

Nose

1. Palpate nose and assess symmetry
2. Check septum
3. Check inside nostrils
4. Verify that patient can breathe through each nostril
5. Verify patient sense of smell is intact
6. Palpate sinuses

Mouth and Throat

1. Moistness and color of lips
2. Inspect teeth and gums
3. Assess buccal mucosa and palate
4. Assess tongue
5. Look at uvula
6. Look at tonsils
7. Palpate jaw joint

Neck and Shoulders

1. Check neck range of motion
2. Check shoulder shrug with resistance
3. Palpate lymph nodes of the head, face, and neck (and under the arms)
4. Palpate neck and trachea
5. Check for JVD

Lungs and Thorax

1. Listen to lung sounds front and back
2. Assess respiratory exclusion level
3. Palpate thorax
4. Assess spinal curvature
5. Ask about coughing, respiratory issues

Circulatory System

1. Palpate carotid and temporal artery bilaterally
2. Listen to heartbeat and heart valves

Gastrointestinal System

1. Inspect abdomen
2. Listen to four quadrants of abdomen for bowel sounds
3. Palpate four quadrants of abdomen for pain/tenderness
4. Ask about problems with bowel or bladder

Arms and Hands

1. Assess range of motion and strength in arms/hands
2. Check all pulses in arms
3. Cap refill test on fingernails
4. Check skin turgor
5. Assess sharp and dull sensation on arms

Legs and Feet

1. Assess range of motion and strength in legs and ankles
2. Check cap refill on toenails
3. Check pulses of legs and feet
4. Assess sharp and dull sensation on legs
5. Assess gait

Genitourinary

Breast

1. Palpate breasts

In-Depth Guide to Conducting a Head-to-Toe Assessment

General Principles for Head-to-Toe Nursing Assessments

Here are four general principles to keep in mind as you conduct your head-to-toe assessment.

#1: Documentation Is Important

Remember that head-to-toe assessment documentation is a critical part of the process. If you don’t write down your findings, how will you remember them all to translate patient needs into a comprehensive care plan? Many people use nursing head-to-toe checklists or forms to make sure they remember everything and to document patient results.

#2: Communicate Throughout

Be sure to communicate clearly with your patient throughout the assessment. Always ask before you start touching the patient, and explain what you are doing as you do it. Additionally, ask patient about how they have been feeling. They are the expert on their own body!

#3: Keep an Eye on Bilateral Symmetry

The human body is, in general, bilaterally symmetrical (i.e., the left side is the same as the right side). When you are assessining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue.

#4: Assess Skin Throughout

The skin is a great barometer of overall wellness. Note if patient’s skin seems unusually pale, flushed, cold, hot, clammy, or dry anywhere throughout the assess. Also not any lesions, abrasions, or rashes.

Step 1: Check Vital Signs and Neurological Indicators

The first things you'll want to check are patient vital signs and overall neurological status.

Oriented x 3

Is patient alert and responsive? Ask if they can tell you their name, if they know where they are, and what day it is. If yes, patient is “alert and oriented x 3.”

Assess Temperature

Take patient temperature and assess whether it is in the normal range. Record whether the temperature was taken orally, rectally, in the ear, at the forehead, or in the armpit as these methods have differing accuracy levels.

Measure Blood Pressure

In professional settings, you may have an automatic blood pressure cuff or you may need to take blood pressure manually. (As a student you’ll likely need to demonstrate that you can take blood pressure manually).

To measure blood pressure manually:

1. First find the brachial pulse, on the inside of the patient’s elbow. Tightly secure the cuff about one inch above the elbow bend (you should be able to fit about two fingers between the cuff and the patient’s arm).
2. Place your stethoscope (diaphragm or bell) over the pulse. Verify that you can hear the brachial pulse.
3. Inflate the cuff until the gauge reads at about 180 mmHg. You should no longer hear the brachial pulse through the stethoscope.
4. Allow the cuff to deflate gradually. The systolic BP is the measurement of the gauge the moment you hear the brachial pulse again. The diastolic BP is the measuring of the gauge when you stop hearing that pulse.

Assess Heart Rate

When you measure the heart rate, you’ll count the beats per minute over a patient pulse point with two fingers (not the thumb, which has its own pulse and can mess up the reading). You’ll usually assess at the radial pulse (wrist) or the carotid pulse (neck). Normal adult BPM is about 60-100, although athletes can have lower heart rates. In a patient with a regular heartbeat, you can take the pulse for 30 seconds and just multiple by two, but if the beat seems irregular, go for at least a full minute.

Assess Respiratory Rate

Respiratory rate is the number of breaths per minute, which you can tell from the rise and fall of the patient’s chest. If you tell a patient you are assessing their breathing, they may actually change their breath rate, so it’s best to assess this surreptitiously after you take the pulse rate. 12 to 20 breaths per minute is the normal adult range. Here’s a quick video guide to checking all the vital signs.

Height and Weight

You may also take patient’s height and weight as part of a head-to-toe assessment.

Step 2: Head and Face

These steps will have you check the overall condition of the head and face. Subsequent sections will be devoted to the eyes, nose, mouth, and ears.

Check Distribution and Condition of Hair

Is hair healthy? Evenly distributed? Is it thinning in places? Note any abnormalities, like unusual brittleness or uneven thinning.

Check Scalp for Bumps, Nits, Lesions, Etc.

Part hair in several places on the scalp to check for bumps, sores, or scabs on the skin. Assess dryness and dandruff. Also check if there are lice or nits present in the hair.

Palpate Skull for Tenderness

Palpate the skull to determine if there are any tender or sore areas.

Check for Symmetrical Facial Movements

Have patient smile, frown, raise eyebrows, and puff out cheeks. If patient can move face at will, movements are symmetrical, and there are no involuntary movement, cranial nerve VII is intact.

Assess Sharp and Dull Sensation on Face

This test assesses the state of cranial nerve V. Hold a sterile, sharp object (like a needle or pin) in one hand and a soft item (like a cotton ball or q-tip) in the other. Ask patient to close eyes and identify whether the sensation they are feeling is sharp or dull. Gently touch the patient’s face in different places with the sharp item or the dull item, varying the order

Step 3: Inspect Eyes

When checking patient eyes, you'll assess both patient vision and the health of the eye tissues like the conjunctiva, sclera, and cornea.

Assess Symmetry

Verify that eyes are symmetrical, that the palpebral fissures are equal and there is no ptosis. Have patient blink; make sure that eyes close completely

Eyebrow and Eyelash Distribution

Assess state of eyelashes and eyebrows; should be symmetrical and evenly distributed.

Check State of Conjunctiva

You can assess the conjunctiva by gently applying downward pressure to the skin below the patient’s eyes. Conjunctiva should be pinkish and free of lesions. Unusually pale conjunctiva can be a sign of anemia, and inflammation or infection can cause red conjunctiva.

Check Sclera

Gently hold patient lids open and assessine whites of the patient’s eyes (can be done simultaneously while assessing conjunctiva). They should be white in color with some capillaries visible. There may be some spots of pigmentation but there should not be lesions or yellowness.

Assess State of Patient’s Corneas

You can assessine the cornea by shining your penlight indirectly across the patient’s eye (so not directly into their eyes but shining from the side). This will illuminate the cornea, which should be smooth and clear. The features of the iris should be clearly visible through the cornea. Additionally, patient should blink when cornea is touched gently with something sterile (the corneal reflex).

PERRLA

PERRLA is an acronym that means that pupils are equal, round, reactive to light and accommodation. This can be tested with a penlight and assesses the state of cranial nerves II and III. You should first look at the pupils to ensure that they are round and equal in size (PER). To check that they are reactive to light, dim the room and move the penlight back and forth between the eyes. Both pupils should constrict equally in response to the light (direct and consensual response). To check that they accommodate, move your finger (or the penlight) slowly closer to the patient’s face. The patient’s pupils should constrict as the object comes closer

Check Six Cardinal Positions of the Gaze

Hold your penlight or finger about one foot in front of patient’s face. Ask them to follow the movements of your penlight or finger with their eyes only (without moving the head/neck). Move the penlight or finger out to the six cardinal positions of the gaze, moving back into the center before proceeding to the next one (like you are drawing out a compass rose). The patient should be able to hold their gaze at each of the six cardinal positions without any jerking (nystagmus). This test assesses the health of cranial nerves III, IV, and VI.

Assess Patient Vision with Snellen Chart

Ask patient to stand the appropriate distance away from the Snellen Chart. (Distance from a standard chart is 20 feet, but your health care setting may use a special chart where the patient should stand a different distance away.) Have them first cover one eye and read the smallest row of letters that they can. Have them repeat with the other eye. If the patient wears glasses or contacts, test both with and without vision correction so you can assess the adequacy of the vision correction

Step 4: Evaluate Ears

As with the eyes, you'll assess both the health of the ear tissue and sensing function (i.e. hearing).

Inspect and Palpate Auricle for Lesions, Tenderness

Skin of the auricle (and behind) should be intact. Cartilage should be firm with no tenderness on palpation. Auricles should be roughly symmetrical.

Look Inside Ear; Assess Ear Discharge and Tympanic Membrane

Pull the pinna/auricle upwards and backwards to straighten the ear canal and assessine the tympanic membrane in adults (pull down and back in children). Some yellow or brown cerumen (earwax) is normal. Tympanic membrane (eardrum) should be a translucent pearly gray color; note abnormal color or rupture.

Tuning Fork Tests (Weber’s Test, Rinne Test)

The Weber and Rinne tests both check for different kinds of hearing loss. For the Weber test, strike the tuning fork and then place the base of the fork on the center of the patient’s forehead. Sounds should be equal in both ears. If sound is stronger in one ear or the other, indicates possible hearing loss.

For the Rinne test, strike the tuning fork and place the base against the mastoid process. Start a stopwatch. Tell the patient to tell you when they stop hearing the sound of the tuning fork. When they stop hearing the sound, move the tuning fork so the forks are in front of the ear (and note the time on your stopwatch). Tell them to tell you when they stop hearing the sound again. Patient should hear the sound of the tuning fork through the air (in front of the air) 2x longer than through the bone. Repeat on the other ear.

Assess Patient Hearing with Whisper Test

Stand next to and a little behind patient (about 2 feet away) so they cannot read your lips. Ask patient to cover opposite ear. Whisper a two-three syllable word and ask patient to repeat it back to you. Repeat with the other ear (and a different word!)

Step 5: Check Nose

You'll be checking the nose both externally and internally.

Palpate Nose and Assess Symmetry

Gently palpate nose for any tenderness. Make sure nose is in midline and symmetrical. Excessive flaring of the nostrils may indicate respiratory distress.

Check Septum

Use penlight to illuminate septum to check that it is midline and not perforated.

Check Inside Nostrils

Shine penlight in each nostril. Check that membranes are pink and that there is no discharge or lesions. Turbinates should not be swollen.

Verify Patency of Nares

Have patient close one nostril with fingertip and breathe in and out through that nostril. Repeat with other nostril. If patient cannot exhale through each naris, the nasal passage is occluded.

Verify Patient Sense of Smell is Intact

Ask patient to close eyes. Hold easily scented item (like coffee beans, cinnamon, or even an alcohol-soaked cotton ball) under the nose and ask patient to identify scent.

Palpate Sinuses

Gently palpate patient frontal and maxillary sinuses. Frontal sinuses are palpable over patient eyebrows. Maxillary sinuses are palpable on the cheek just outside the nares. Patient should not feel tenderness to pressure.

Step 6: Probe Mouth and Throat

Again, like the nose, you'll assess the health of the mouth and throat both externally and by looking inside.

Moistness and Color of Lips

Lips should be colorful, pinkish, roughly symmetrical, and free of lesions. Very cracked or chapped lips could be a symptom of a number of issues, from dehydration to wind exposure to autoimmune conditions.

Inspect Teeth and Gums

Assess patient teeth for number (28 in children, 32 in adults), color, and alignment. Note any cavities or chips. Assess gums for bleeding, puffiness, or retraction (the pulling of the gum away from the tooth, which can give teeth an “elongated” appearance). Also note presence of halitosis; gum disease and oral infection are some of the most common causes of bad breath.

Assess Buccal Mucosa and Palate

The membranes of the mouth and cheek should be pink, moist, and free of lesions.

Tongue

Tongue should be midline, pink with white taste buds, and free of lesions. Patient should be able to move tongue without difficulty.

Look at Uvula

Patient uvula should be in the midline, pink or reddish in color, and free of swelling or lesions. When the patients says “ah,” uvula should move forward and up. (This tests cranial nerve X.)

Look at Tonsils

Depress tongue to inspect tonsils for inflammation, infection, swelling and tonsil stones. Infected tonsils are often red and puffy with white or yellow patches.

Palpate Jaw Joint

Palpate the jaw joint (the temporomandibular joint) while patient’s mouth is closed, and then again while it is open. Patient should be able to open and close mouth without pain and there should be no pain on palpation.

Step 7: Neck and Shoulders

In the neck and shoulders, you'll primarily assess musculoskeletal function, but you'll also assess the lymph nodes and a few other things.

Check Neck Range of Motion

Ask patient to look up, down, left, and right to assess that they have full range of motion in the neck. Ask if there is any pain (should be painless).

Check Shoulder Shrug with Resistance

Ask patient to shrug shoulders. Movement should be symmetrical and painless. Then, place hands on shoulders and ask patient to shrug again. Apply resistance. Patient should still be able to shrug with about equal force on each side.

Palpate Lymph Nodes of the Head, Face, and Neck (and Under the Arms)

Using the first two or three fingers (using the flat pads as opposed to the fingertips), you’ll palpate the following lymph nodes by moving the skin over the area in a circular motion: the occipital, posterior auricular, pre-auricular, sub-mandibular, sub-mental, anterior cervical chain, posterior cervical chain, and the supraclavicular lymph nodes. You may also wish to palpate the axillary lymph nodes, under the arms.

Observe/Palpate Trachea and Neck

Palpate neck to feel for any lumps, deviations, or tenderness in the neck, especially the trachea area. You may also wish to palpate the thyroid, which requires a glass of water and can be done from the front (anterior approach) or behind (posterior approach).

Check for JVD

Jugular Venous Distension refers simply to an abnormally full or bulging jugular vein in the neck. It can be a sign of serious heart disease. To assess JVD, you’ll want to lay the patient down with the head of the hospital bed at a 45-degree angle.

Step 8: Assess Lungs and Thorax

When assessining the chest area, you'll primarily be assessing respiratory function.

Listen to Lung Sounds Front and Back

You’ll be listening to the lungs up and down each lung, front and back, with your stethoscope to assess for any irregular breathing sounds.

Assess Respiratory Expansion Level

To assess respiratory expansion, place your hands on the patient’s mid-back with thumbs at midline. Ask them to take a deep breath. Both sides of the chest should expand equally with breath.

Palpate thorax

Palpate the thorax for any areas of tenderness, lumps, asymmetry, lesions, etc.

Assess Spinal Curvature

Spine should appear vertical when viewed from the back (with no scoliosis). Should exhibit normal curvature from the side.

Ask About Coughing, Respiratory Issues

Ask patient if they are experiencing any coughing or other respiratory problems. If they are coughing, is it a dry cough or a wet cough?

Step 9: Check Circulatory System Function

Assessing the circulatory system is something you'll actually be doing throughout the assess as you assess various pulses. but as you are assessing the chest, you'll want to assessine the heart.

Palpate the Carotid and Temporal Pulses Bilaterally

Using index and middle fingers, feel the carotid pulse (at the side of the neck) and the temporal pulse (at the temple). Since you already checked pulse rate, you don’t need to listen for a whole minute; just verify that the pulse is palpable and regular in rhythm.

Listen to Heartbeat and Heart Valves

You’ll need to listen to the patient’s heart in four places with your stethoscope: the aortic valve, the pulmonic valve, the tricuspid valve, and the mitral valve. You’ll be listening for any irregularities in rhythm or irregular sounds during valve closures.

Step 9: Review Gastrointestinal System

You'll assess the gastrointestinal system by assessining the abdomen and asking the patient questions.

Inspect Abdomen

Inspect patient abdomen for any visible lumps, lesions, or distension or concavity.

Listen to 4 Quadrants of Abdomen for Bowel Sounds

Visually dividing the abdomen into four quadrants with the belly button as the midline, listen to bowel sounds in each quadrant. Judge if sounds are hypoactive, hyperactive, or absent. If you do hear sounds, you may only need to listen for several seconds in each quadrant. However, you should listen to each quadrant for five minutes before you determine that there are no bowel sounds.

Palpate 4 Quadrants of Abdomen for Pain/Tenderness

After you listen to the sounds, palpate the four quadrants of the abdomen for any pain, tenderness, or lumps with your fingers

Ask About Problems With Bowel or Bladder

Ask patient when their last bowel movement was. Also ask if appetite, bowel movements, and urination have been normal.

Step 10: Inspect Arms and Hands

In the extremities, you'll assess musculoskeletal function, sensory function, circulation, and tissue perfusion.

Assess Range of Motion and Strength in Arms

Have patient demonstrate range of motion in arms and hands. They should be able to roll shoulders, show flexion and extension of the elbow joint, circle the hands around the wrist joint, and demonstrate full flexion and extension of the wrist without pain. Also have patient squeeze push against your hands, pull your hands towards them, and squeeze your fingers to assess strength, which should be equal bilaterally.

Check All Pulses in Arms

There are two major pulses in the arms: the radial pulse (at the wrist) and the brachial pulse (in the inner elbow). If you already checked the radial and brachial pulses while you were taking vitals, you can skip this step. It’s most important to check that the pulses are palpable and regular in rhythm.

Cap Refill Test on Fingernails

To check tissue perfusion, pinch one of the patient’s fingertips, applying pressure to the nail. When you release the fingertip, the nail bed should return to a normal color within 3 seconds.

Check Skin Turgor

On the back of the hand or forearm, pinch skin. It should immediately snap back to position upon release without “tenting” (remaining pinched upright). Tenting indicates dehydration or fluid volume deficit (link). However, note that this is not an effective test of skin turgor on elderly patients, as lower skin elasticity means their skin often tents regardless of their fluid levels!

Assess Sharp and Dull Sensation on Arms

Take your sterile, sharp object (like a needle or pin) in one hand and your soft item (like a cotton ball or q-tip) in the other. Ask patient to close eyes and identify whether the sensation they are feeling is sharp or dull. Gently touch the patient’s arms in different places with the sharp item or the dull item, varying the order.

  

Step 11: Legs and Feet

You'll perform most of the same assessinations on the lower extremities that you did on the upper extremities.

Assess Range of Motion and Strength in Legs and Ankles

You should test range of motion of the lower extremities with the patient lying down. Patient should be able to flex and extend the ankle joint, and circle the foot. Patient should also be able to bend the knee and then move leg outward (to test hip ROM) on each side. There should be no pain.

To assess strength, patient should push against your hands on the top of their feet, push down against your hands on the bottom of your feet, and push up against your hand on their shin. Strength should be equal bilaterally.

Check Cap Refill on Toenails

Perform the cap refill test on one of the patient’s toenails. After applying pressure, the patient’s nail bed should return to a normal color by 3 seconds.

Check Pulses of Legs and Feet

There are four major pulse points on the legs and feet: femoral (hip/groin), popliteal (behind knee), posterior tibial (ankle) and dorsalis pedis (top of foot). Palpate the pulses of the legs and feet with your middle two or three fingers (not the thumb, which has its own pulse!) As you’ve already taken the pulse rate at this point, it’s not necessarily the rate that’s critical here but the regularity and strength of the pulse. Pulse should be palpable and regular.

Assess Sharp and Dull Sensation on Legs

Repeat the sharp and dull sensation test on the patient’s legs. Take your sterile, sharp object and your soft item. Ask patient to close eyes and identify whether the sensation they are feeling is sharp or dull. Gently touch the patient’s legs in different places with the sharp item or the dull item, varying the order.

Assess Gait

Observe patient gait (can be done when patient gets up to complete Snellen chart). Should be symmetrical, regular, and balanced.

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Optional Step 1: Complete Genitourinary

You may not always perform a genitourinary assess as part of a head-to-toe assessment. However, if you do, here are the main things you’ll be checking for:

Check Pubic Hair for Lice and Nits

Assess for presence of lice or nits in pubic hair.

Check for Tenderness, Lumps, Lesion

Optional Step 2: Perform Breast inspection

You may or may not need to perform a breast assess in your head-to-toe assessment—sometimes it’s advised to only perform them on symptomatic men or older women. However, here’s an in-depth guide to palpating the breast and feeling for unusual lumps.