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Head to Toe Assessment
My name is Melissa, a student nurse at Bishop State, and I will be performing a head to toe assessment on you today. During this assessment, there will be times when I will need to touch you and reposition you is that ok?
Hand Hygiene, put on gloves, provide privacy.
Now I am going to ask you a series of questions… What is your name? What year is it? Where are you? What is your date of birth? Arousal/orientation x 3 intact Take your right finger and touch your nose and then touch your left ear Attention/orientation intact What does raining cats and dogs mean? What is 1+1+2? What did you have for dinner? Language Expression/Comprehension intact Thinking and memory intact Vital Signs: Previously taken: BP: 124/ Apical Pulse: 80 Radial Pulse: 78 with a pulse deficit of 2 Repsirations: 16 Temp: 98. Height 5’3” Weight 130 Snellen Chart Eye sight vision is 20/ Are you in any pain? Physical Appearance: 22 year old female, alert and oriented, cooperative, neat and clean, articulates clearly, facial expression appropriate for situation. Inspection Skin: Feel the hands and arms with back of hand, check temperature and skin turgor. Color tan, evenly toned, thin and warm bilaterally, good skin turgor. Any tenderness, any pain? No tenderness, no pain, no lesions.
Nails: Capillary refill is less than 2 seconds, surface flat, edges smooth, clean and round, no clubbing noted. Hair/Head: Hair is blonde, thin and evenly distributed over scalp. Palpate the head and ask if any pain or tenderness. Head is normocephalic, symmetrical and midline. Scalp non-tender, smooth and clean, no lesions or infestations. Facial structures are symmetrical, relaxed and aligned. Nose and mouth are midline, no involuntary movements noted, head is erect. Eyes: Place penlight on side of each eye to examine the lens. Eyebrows present and symmetrical, eye lashes evenly distributed, eyelids have no edema, no lesions, no discharge, (Pull bottom of eyelids down and inspect conjunctiva) conjunctiva is pink, scelera white, lens have no cloudiness, cornea is smooth and clear. Eyeballs are moist and glossy, aligned normally in their sockets with no protrusion or sunken appearance, symmetrical and level with top of ears. Pupillary Response: Have pt stare at an object past your shoulder. Move the penlight from the outer side of the eye towards the nose. Pupils constrict and are 3 mm Accoommodation: Have pt to stare above shoulder and I will hold my finger in front of their nose approximately 8 inches and have them focus on top of finger. Looking for eyes to constrict and converge. PERRLA – pupils are equal, round, and reactive to light and accommodation. Six fields of Gaze : Have patient focus on penlight, hold head still, but follow penlight with their eyes clockwise and do the six fields of gaze. Extraocular muscles intact. Move symmetrically, smooth, and with no nystagmus noted. Ears: Palpate auricle. Ears are equal in size bilaterally, skin tone even with face, no lesions, lumps, no discharge, non- tender. Palpate mastoid and tragus: Any pain? Any tenderness? No pain or tenderness noted. Whisper Test: Stand behind patient and have them occlude each ear one at the time, as you whisper ABC on one side and 123 on the other. Patient should be able to repeat back to you. Pt able to hear whispered words bilaterally. Hearing intact. Nose/Sinuses: Hold head back, shine light inside each nare and palpate sinuses. Any tenderness? Any pain?
Have patient flex knees. Inspect abdomen by shining the penlight across the surface of abdomen and look for any pulsations. Then shine penlight on top of abdomen for pulsations. Abdomen is round and symmetrical. Skin surface is smooth, umbilicus is midline and inverted Auscultate Abdomen starting with RLQ, RUQ, LUQ and LLQ Bowels sounds are present in all four quadrants. Palpate lightly in all four quadrants Abdomen is soft and non-tender. No guarding, no swelling, no masses, no organomegaly noted. Palpate inguinal lymph nodes. No pain No tenderness. Non-palpable. Inspection entire body for edema and varicosities. No edema, no swelling and no varicosities noted. Palpate all peripheral pulses. All pulses are equal bilaterally +2. ROM: Shoulder, elbow, wrist, fingers, hip, knee, ankles, and toes Full ROM in all joints. Smooth movement, no pain, no tenderness noted. Deep tendon reflex for patellar – one laying down and other sitting up. Also do Babinski reflex. Reflexes are intact with a negative Babinski reflex Have patient stand up and walk. Tandem walking and heel to toe on the way back. Normal gait, turns were smooth, no involuntary movement, arms swing is coordinated with knee bend, stands erect with good posture. Any pain, any tenderness when you walk? No pain no tenderness noted. Have patient bend over and palpate spinous processes, and paravertebral muscles then have patient sit and test muscle strength by pulling arm against resistance and legs. Muscle strength is intact and equal bilaterally in upper and lower extremities. Test sensory motor by doing sharp and dull test with eyes closed with soft object and sharp object on face and chest and arms. (Floss stick and cotton ball) Pain sensation intact This wraps up your head to toe assessment. Do you have any questions?
