NursingStudyHub

The Order of a Head-to-Toe Assessment

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by

Liu
in

Assessment Area Assessment Tasks
General Status

  • Vital signs
  • Heart rate
  • Blood pressure
  • Temperature
  • Pulse oximetry
  • Respiratory rate
  • Pain
  • Height/Weight/BMI
 Assess pain using the appropriate pain scale for the patient

  • Numerical Scale
  • Wong-Baker Faces Pain Scale
  • FLACC Pain Scale
  • CRIES Pain Scale
  • COMFORT Pain Scale
  • McGill Pain Questionnaire
  • Color Analog Pain Scale
Head, Ears, Eyes, Nose, Throat (HEENT)

  • Inspect head tilt
  • Inspect skull and scalp
  • Inspect facial features
  • Palpate head and scalp
  • Auscultate temporal arteries if appropriate
  • Inspect  the color of lips and moistness
  • Inspect teeth and gums
  • Inspect  buccal mucosa and palate
  • Inspect  Tongue
  • Inspect  at uvula
  • Inspect  tonsils
  • Palpate nose and assess symmetry
  • Inspect septum and inside nostrils
  • Inspect  patency of nares
  • Inspect  patient’s sense of smell
  • Palpate sinuses
  • Perform whisper test
  • Perform tuning Fork test (Weber’s test, Rinne test)
  • Inspect  ear discharge and tympanic membrane
  • Inspect  conjunctiva and sclera
  • Inspect  eye symmetry
  • PERRLA
  • Check vision with Snellen Chart including distant visual acuity and near visual acuity.
  • Check six cardinal positions of the gaze
  • Inspect the external auditory canal
  • Inspect the tympanic membrane
  • Check for size, shape, symmetry, lesions, trauma
  • Check for thickening, hardness, and tenderness
  • Observe for masses, webbing, and skinfolds
Neck

  • Palpate lymph nodes
    • Parotid and retropharyngeal (tonsillar)
    • Submandibular
    • Submental
    • Sublingual (facial)
    • Superficial anterior Cervical
    • Superficial posterior cervical
    • Preauricular and postauricular
    • Sternocleidomastoid
    • Occipital
    • Supraclavicular
  • Inspect and palpate trachea and neck
  • Inspect for Jugular Venous Distention
  • Inspect neck range of motion
  • Inspect shoulder shrug with resistance
  • Check for symmetry, tenderness, shape
  • Check thyroid for size, shape, configuration, tenderness, nodules
Respiratory 

  • Inspect the chest
  • Perform direct and indirect percussion on the chest
  • Auscultate lung sounds posteriorly and anteriorly
  • Inspect respiratory expansion level
  • Ask about coughing
  • Palpate thorax
  • Inspect nasal flaring and pursed lip breathing
  • Inspect configuration
  • Palpate for tenderness and sensation
  • Palpate for crepitus and fremitus
  • Percuss for diaphragmatic excursion
  • Percuss for tone
  

  • Inspect chest for size, shape, symmetry, color, superficial venous patterns, and prominence of ribs
  • Evaluate respirations for rate and rhythm
  • Auscultate for intensity, pitch, duration, and quality of breath sounds
Cardiac

  • Palpate the carotid and temporal pulses bilaterally
  • Auscultate the five areas of the heart
  • Inspect the precordium
  • Palpate apical pulse
  • Assess for murmurs
  • Listen for heart rate, rhythm, S1 and S2
Abdomen

  • Inspect abdomen
  • Auscultate 4 quadrants of the abdomen for bowel sounds
  • Palpate 4 quadrants of the abdomen for pain/tenderness
  • Percuss the 4 quadrants of the abdomen
  • Ask about problems with bowel or bladder
  • Inspect umbilicus
  • Inspect for aortic pulsations and peristaltic waves
  • Palpate the umbilicus and surrounding area for swellings, bulges, or masses
  • Inspect skin characteristics, venous patterns, symmetry, surface motion
  • Inspect masses, hernia, separation of the muscles
  • Listen for bruits
  • Check for tone, liver borders
Pulses

  • Palpate pulses in arms/legs/feet including,
    • Brachial (in infants)
    • Radial
    • Femoral
    • Posterior tibial
    • Dorsalis pedis
  • Ensure pulse are palpable and present
Extremities

  • Assess range of motion and strength in arms/legs/ankles
  • Assess sharp and dull sensation on arms/legs
  • Perform capillary refill on fingernails/toenails
  • Palpate each joint in the hand and write
  • Test for carpal tunnel syndrome by performing Phalen’s test
  • Inspect  for muscle tone, warmth, tenderness, swelling, and crepitus
  • Inspect  for alignment, size, deformities, contour and symmetry
Skin

  • Inspect skin turgor
  • Inspect  for lesions, abrasions, rashes
  • Inspect  for tenderness, lumps, lesions
  • Inspect  if the patient is pale, clammy, dry, cold, hot, flushed
  • Inspect  for moisture, temperature, texture, turgor, elasticity
  • Inspect  for color, distribution, density
  • Identify pigmentation, length, redness, swelling, pain, growths
Neurological

  • Test cranial nerves I through XII
    • CN I – Olfactory
    • CN II – Optic
    • CN III – Oculomotor
    • CN IV -Trochlear
    • CN V – Trigeminal
    • CN VI – Abducens
    • CN VII – Facial
    • CN VIII – Acoustic/Vestibulocochlear
    • CN IX – Glossopharyngeal
    • CN X – Vagus
    • CN XI – Spinal Accessory
    • CN XII – Hypoglossal
  • Evaluate balance using the Romberg test
  • Evaluate coordination and fine motor skills
  • Test primary sensory responses
  • Oriented x3
  • Assess gait
  • Assess superficial and deep tendon reflexes
  • Check the Glasgow Coma Scale score
  • Gait: posture, rhythm, sequence of stride and arm movements
  • Inspect for superficial touch and superficial pain response
Genitalia (this will vary on patient)

  • Palpate inguinal lymph nodes
  • Inspect labia majora, labia minora, clitoris, urethral meatus, and vaginal opening
  • Inspect the base of the penis and pubic hair
  • Inspect the skin of the shaft
  • Palpate the shaft
  • Inspect the foreskin and glans
  • Inspect the size, shape, and position of scrotum
  • Palpate the scrotum
  • Inspect for inguinal or femoral hernia

How to Prepare for Head-to-Toe Assessments

“Like all clinical settings, standard precautions (formerly universal precautions) should always be practiced with each and every patient to protect both the nurse and patient,” states Zucchero. “The primary goal of standard precautions is to prevent the exchange of blood and body fluids and includes hand hygiene, use of personal protective equipment, and safe handling and cleaning of potentially contaminated equipment or surfaces.”

Techniques Used During Physical Assessment

There are four techniques utilized during a physical assessment including, inspection, palpation, percussion, and auscultation. It’s important to note that not all four techniques will be utilized during every assessment.

For example, APRNs will regularly palpate during an exam; however, a bedside med-surg nurse may not have a reason to. It is important that nursing students and nurses know each technique, how to utilize them, when to use them, and why they are important.

Inspection

This is the first technique used in any assessment. You will want to fully inspect your patient before completing other aspects of the physical assessment. Utilize visual examination to inspect different areas of the body. You will want to note the overall appearance and color.

Palpation

This is the act of touching a patient to determine abnormalities on or in the body. There are two different techniques used for palpation: light and deep palpation.

Light palpation is gentle and gives information about skin texture and moisture, fluids, muscle guarding, and some superficial tenderness the patient may be experiencing.

Deep palpation explores the internal structures of the body to a depth of four to five centimeters.

Percussion

Nurses will palpate different body parts for sound vibrations. The most common is palpating the abdomen. Palpation can confirm the presence of air, fluid, and/or solids. It also is utilized to determine organ size, shape, and position.

Auscultation

The final method used during a physical assessment is auscultation, or listening with a stethoscope to the different body systems of your patient. You will want to listen for lung sounds, heart sounds, and bowel sounds. APRNs can also be expected to listen to the neck for bruits.

Head-to-Toe Assessment Equipment Checklist

Depending on the type of assessment conducted, the nurse may need specific equipment.

Basic equipment includes:

  •  Gloves
  • Thermometer
  • Blood pressure cuff
  • Watch
  • Scale
  • Height wall ruler
  • Tape measure,
  • Penlight
  • Stethoscope

Additional equipment for more comprehensive examinations would include,

  •  Otoscope
  • Ophthalmoscope
  • Reflex hammer
  • Tongue depressor
  • Sterile sharp object (like toothpick or pin)
  • Sterile soft object (like cotton ball)
  • Something for the patient to smell (like an alcohol swab)

How Long Are Head-to-Toe Assessments?

Ferere explains that the duration of the exam is directly correlated to the patient’s overall health status.

“Health patients with limited health histories may be completed in less than 30 minutes,” she says. “Many health practices have patients complete health history and pre-visit forms prior to presentation for a comprehensive visit. Review of these forms in advance can certainly reduce the required visit time.”