9/9/13

Nursing Head-to-Toe Assessment Cheat Sheet - Nurseslabs

Nursing Assessment in Bullet Form
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a good skin turgor and skin’s temperature is within normal limit. Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. There are also no signs of infection and infestation observed. Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and is intact with the epidermis. When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.
Contents [hide] 1 Nursing Assessment in Bullet Form 1.1 Integument 1.2 Head 1.3 Eyes and Vision 1.4 Ears and Hearing 1.5 Nose and Sinus 1.6 Thorax and Lungs 1.7 Extremities 2 Nursing Assessment in Tabular Form

Head
Head: The head of the client is rounded; normocephalic and symmetrical. Skull: There are no nodules or masses and depressions when palpated. Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.

Eyes and Vision
Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows. Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward. Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately 15-20 times per minute. Eyes The Bulbar conjunctiva appeared transparent with few capillaries evident. The sclera appeared white. The palpebral conjunctiva appeared shiny, smooth and pink. There is no edema or tearing of the lacrimal gland. Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched. The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to light accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when object is moved towards the nose. When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. When testing for the Extraoccular Muscle, both eyes of the client coordinately moved in unison with parallel alignment. The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing
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When nails pressed between the fingers (Blanch Test). The client manifested quiet. The pinna recoils when folded. The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible. They are normally firm and showed smooth. There is a presence of thin whitish coating. The chest wall is intact with no tenderness and masses. There were symmetric movements caused associated with client’s respiration. there were no tenderness and lesions Mouth: The lips of the client are uniformly pink. no retraction of gums. The lymph nodes of the client are not palpable. firm and not tender. the nails return to usual color in less than 4 seconds. symmetric and have a smooth texture. When palpating for the texture. The right and left shoulders and hips are of the same height. the client was able to hear ticking in both ears. nurseslabs.com/nursing-assessment-cheat-sheet/ 2/7 . The jugular veins are not visible. moist. The trachea is placed in the midline of the neck. Heart: There were no visible pulsations on the aortic and pulmonic areas. The uvula of the client is positioned in the midline of the soft palate. rhythmic and effortless respirations. The auricles are aligned with the outer canthus of eye. When lightly palpated. soft. Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. Nose and Sinus Nose: The nose appeared symmetric. glistening and with elastic texture. There was no presence of discharge or flaring. The tongue of the client is centrally positioned. There is no presence of heaves or lifts. moist. The client was able to purse his lips when asked to whistle. Teeth and Gums: There are no discoloration of the enamels. There’s a full and symmetric expansion and the thumbs separate 23 cm during deep inspiration when assessing for the respiratory excursion. Thorax and Lungs Lungs / Chest: The spine is vertically aligned. It is pink in color. straight and uniform in color.Nurseslabs Ears: The Auricles are symmetrical and has the same color with his facial skin. Neck: The neck muscles are equal in size. During the assessment of Watch tick test. moist and slightly rough. Extremities The extremities are symmetrical in size and length. pinkish in color of gums The buccal mucosa of the client appeared as uniformly pink. the auricles are mobile. The client showed coordinated. The smooth palates are light pink and smooth while the hard palate has a more irregular texture. smooth head movement with no discomfort. The abdomen has a symmetric contour. Muscles: The muscles are not palpable with the absence of tremors.9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet . coordinated movements.

normocephalic and symmetrical. pink Sclera Appears white. Lacrimal gland. smooth.With short.com/nursing-assessment-cheat-sheet/ 3/7 . With fair complexion.9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet . palpebral fissures equal in size. Joints: There were no swelling. nurseslabs. Eyelashes Eyelids Skin intact with no discharges and no discoloration.Eyebrows are symmetrically aligned and have equal movement. Convex and with good capillary refill time of 2 seconds. Symmetrical facial movement. Equally distributed and curled slightly outward. tenderness and swelling.Nurseslabs Bones: There were no presence of bone deformities.Absence of nodules or masses. Smooth and has intact epidermisWith short and clean fingernails and toenails. tenderness and joints move smoothly. symmetric nasolabial folds. black and shiny hair.With presence of pediculosis Capitis. Nasolacrimal duct No edema or tenderness over the lacrimal gland and no tearing. Lacrimal sac. FINDINGS Nails Skull Face Eyes and Vision Eyebrows Hair evenly distributed with skin intact.Lids close symmetrically and blinks involuntary. Rounded. Transparent with capillaries slightly visible Bulbar conjunctiva Palpebral Conjunctiva Shiny. smooth and has uniform consistency. With dry skin Hair Evenly distributed hair. Nursing Assessment in Tabular Form ASSESSMENT Integumentary Skin When skin is pinched it goes to previous state immediately (2 seconds).

auricle is aligned with the outer canthus of the eye. pale lips. Symmetrical. Hold penlight in the periphery and ask the client when the moving object is spotted. pupils equally rounded and reactive to light and accommodation. pupils constrict when looking at near objects. She was able to read the newsprint at a distance of 8 inches. External Ear Canal Hearing Acuity Test Voice sound audible. and pinna recoils after it is being folded.com/nursing-assessment-cheat-sheet/ . the client can see objects at the periphery which is done by having the client sit directly facing the student nurse at a distance of 2-3 feet. converge when object is moved toward the nose at four inches distance and by using penlight. air moves freely as the clients breathes through the nares. Visual Fields Visual Acuity Ear and Hearing Auricles Color of the auricles is same as facial skin. Able to identify letter/read in the newsprints at a distance of fourteen inches. The right eye is covered with a card and asked to look directly at the student nurse’s nose. Corneal sensitivity Pupils Black. brown gums and able to 4/7 Nasal Cavity Mouth and nurseslabs. dilates at far objects. When looking straight ahead. smooth and shiny upon inspection by the use of a penlight which is held in an oblique angle of the eye and moving the light slowly across the eye. Watch Tick Test Able to hear ticking on right ear at a distance of one inch and was able to hear the ticking on the left ear at the same distance Nose and sinuses External Nose Symmetric and straight. symmetrical. non-tender. firm.Nurseslabs Cornea Clarity and texture Transparent.9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet . equal in size with consensual and direct reaction.Has brown eyes . no flaring. Blinks when the cornea is touched through a cotton wisp from the back of the client. Mucosa is pink. Without impacted cerumen. uniform in color. mobile. no lesions and nasal septum intact and in middle with no tenderness.

smooth coordinated movements. With dental caries and decayed lower molars Tongue and floor of the mouth Central position. left and right shoulders and hips are at the same height. No masses palpated. glands ascend but not visible in female during swallowing and visible in males. Upper Extremities Lower Extremities Muscles Without scars and lesions on both extremities. Uvula Gag Reflex Neck Head movement Positioned midline of soft palate. symmetric contour. head laterally flexes. pink but with whitish coating which is normal. With minimal scars on lower extremities Equal in size both sides of the body. With normal breath sounds without dyspnea. 100% of normal full movement against gravity and full resistance. spinal column is straight. with veins prominent in the floor of the mouth. rhythmic and effortless respiration Breath Sounds Anterior Thorax Abdomen Abdominal movements Auscultation of bowel sounds Unblemished skin. With audible sounds of 23 bowel sounds/minute. With equal strength Non-palpable. undistended. Tongue movement Moves when asked to move without difficulty and without tenderness upon palpation. uniform in color. Quiet. Coordinated. Present which is elicited through the use of a tongue depressor. 5/7 nurseslabs.Nurseslabs Oropharynx Teeth purse lips. non tender Not visible on inspection. smooth movement with no discomfort. Symmetrical movements cause by respirations. Muscle strength Lymph Nodes Thyroid Gland Thorax and lungs Posterior thorax Spinal alignment Chest symmetrical Spine vertically aligned.9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet . Positioned at the midline without tenderness and flexes easily.com/nursing-assessment-cheat-sheet/ . head laterally rotates and hyperextends.

Perform with accuracy and rapidity. Perform with coordinating and rapidity. E4V5M6 Has upright posture and steady gait with opposing arm swing unaided and maintaining balance.Nurseslabs Bones and Joints Mental Status Language Orientation Attention span Level of Consciousness Motor Function Gross Motor and Balance Walking gait No deformities or swelling. A total of 15 points indicative of complete  orientation and alertness. Quick Nursing Assessment Cheatsheet. Can express oneself by speech or sign. Able to discriminate between sharp and dull sensation when touched with needle and cotton. nursing fundamental cheat sheet. Rapidly touches each finger to thumb with each hand. Able to concentrate as evidence by answering the questions appropriately. joints move smoothly. assessment sheet for nurses. psychiatric assessment cheat sheet. Oriented to a person. Maintained stance for at least five (5) seconds. Repeatedly and rhythmically touches the nose. date or time.9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet .com/nursing-assessment-cheat-sheet/ 6/7 . nursing drug guide cheat sheet nurseslabs. nursing assessment cheat sheet. Can alternately supinate and pronate hands at rapid pace. head to toe assessment cheat sheet. Standing on one foot with eyes closed Heel toe walking Toe or heel walking Fine motor test for Upper Extremities Finger to nose test Alternating supination and pronation of hands on knees Finger to nose and to the nurse’s finger Fingers to fingers Fingers to thumb Fine motor test for the Lower Extremities Pain sensation Maintains a heel toe walking along a straight line Able to walk several steps in toes/heels. place.

com/nursing-assessment-cheat-sheet/ 7/7 .9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet .Nurseslabs nurseslabs.

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