HEAD-TO-TOE ASSESSMENT

1. Provide privacy
2. Introduce yourself and explain the procedure
“Good morning, I’m Therese and I am going to be your nurse today. So, I will be performing an
assessment; going from the head and down and I’ll also give you directions and explanations as
I go along the way. Does that sound good?”
3. Perform hand hygiene

NEUROLOGICAL:
- Can you state your name and age please?
- Can you tell me where we’re at?
- Can you tell me the date today?
- Can you tell me what we’re doing today?
Alert and oriented x4

APPEARANCE:
Well-groomed, well-nourished, well-developed, skin color is even and appropriate for pt’s
race and ethnicity, facial features are symmetric, posture is upright and is dressed
appropriate to weather and situation.
HEAD:
- Inspect the head for any abnormalities
- Palpate scalp and hair to feel for masses, infestations, baldness
- Temporal artery
- Test Cranial Nerve VII Facial:
Can you close your eyes tightly?
Raise your eyebrows
Can you smile, frown and puff your cheeks?
- Test cranial nerve V Trigeminal:
Can you clench your teeth (Feel for the masseter and temporal muscles)
Can you open and close your mouth (feel for crepitus)
Tell me when you feel me touching your face
Check for sensation using a cotton ball and pin after
- Palpate maxillary and frontal sinuses
EYES:
- Pull lower lid and look up and inspect sclera and conjunctivae
- Test cranial nerve III, IV, VI:
Head still and follow penlight (6 cardinal fields of gaze)
Have patient look at a distance and shine the penlight from side to side (check dilation
and constriction)
Have patient look at your nose and move penlight closer to the patient’s face (check for
accommodation)
Cover one eye and check for peripheral vision
EARS:
- Inspect and look for any abnormalities
- Palpate ear and check for tenderness and masses
- Palpate targus and check for tenderness or pain
- Palpate mastoid process
- Test cranial nerve VIII Vestibulocochlear:
Cover one ear and whisper on the other
NOSE:
- Are you having any trouble with your nose?
- Check septum
- Check patency of the nose, cover one nostril and breathe through the other
- Check for drainage or polyps inside the nose with a penlight
- Test Cranial nerve I Olfactory:
Close your eyes and place something in front and tell me what you smell.
MOUTH:
- Inspect lips
- Inspect inside of the mouth
- Test cranial nerve XII hypoglossal:
Stick out tongue and move it side to side
- Inspect inside: cheeks, tongue, cavities, dental caries, thrush, soft and hard palate,
Test cranial nerve IX Glossopharyngeal:
Have patient say “ah” then check for uvula (must be midline and move up)
- Test cranial nerve X Vagus:
Check for gag reflex
NECK:
- Inspect trachea for lesions or masses
- Test cranial nerve XI Accessory:
Move head side to side, up and down
Shrug shoulders
45 degrees – jugular vein
- Palpate trachea and feel for tenderness, masses, pain
- Palpate lymph nodes:
 Preauricular
 Postauricular
 Occipital
 Parotid
 Jugulodigastric
 Submandibular
 Submental
 Superficial cervical
 Deep cervical
 Posterior cervical
 Supraclavicular
None of the lymph nodes are palpable which means you do not have any signs of
infection
- Palpate carotid artery both sides
- Auscultate carotid artery for bruits using bell, let patient breathe in an out then hold
while exhaling
UPPER EXTREMITIES:
- Check skin color
- Palpate radial artery bilaterally
- Check capillary refill (less than 2 seconds)
- Check skin turgor
- Check range of motion for fingers and hands
- Check for clubbing
- Palpate brachial artery bilaterally
- Test upper body strength:
Grip fingers
Push against my hand and push against patient’s
Raise arms up, side, and shrug
Squeeze and release the fingers, wrist movement inward side and out
- Check elbow joint for crepitus
 - Drift: close eyes and extend arms (Romberg test)
- Test for sensation: using pin and a dull pin
- Check for elbow reflex
CHEST:
- Inspect chest for abnormalities
- Inspect chest for breathing
LUNGS:
- POSTERIOR: Palpate for any abnormalities
- Place hands at T10 and ask patient to take a deep breath (respiratory excursions are
normal and expanding equally on both sides)
- Feel for tactile fremitus by placing hand on back and let the patient say 99
- Percuss lungs (all lung fields are resonant)
- Auscultate lungs apex, 2nd,4th, mid axillary (all lung fields are clear and so signs of any
adventitious sounds)
- ANTERIOR: Palpate for any abnormalities
- Feel for tactile fremitus by placing hand on back and let the patient say 99
- Percuss lungs (all lung fields are resonant to percussion)
- Auscultate lungs apex, 2nd,4th, mid axillary (all lung fields are clear and so signs of any
adventitious sounds)
HEART:
- Auscultate aortic, pulmonic, erb’s, tricuspid, mitral with diaphragm and repeat using bell
for any heart murmurs and abnormal blood flows (No misbeats, gaps on circulation)
ABDOMEN:
- Are you having any stomach issues?
- When was your last bowel movement?
- Do you feel any pain when you are peeing?
- Inspect abdomen: abdomen looks flat, no peristaltic waves, no visible pulsations)
- Auscultate: RLQ, RUQ, LUQ, LLQ (bowl sounds are normal and active in all four
quadrants)
- Auscultate vascular sounds: Aorta, renal arteries, iliac arteries (No bruits noted)
- Percuss abdomen
- Palpate from light to deep and do bimanual palpations to feel kidney, palpate aorta
- Abdominal reflex using cotton
LOWER EXTREMITIES:
- Inspect for hair growth, swelling, redness
- Palpate pulses: Popliteal, posterior tibial, dorsalis pedis
 - Capillary refill
- Bobinsky reflex
- Test for sensation: using pin and a dull pin
- Check patellar reflex
NEUROLOGICAL COORDINATION TEST:
- Flip hands
- Take an object and put it in patient’s hand, let them tell what that object is
(stereognosis- ability to recognize an object without looking at it)
Have patient in standing position:
- Palpate spine, check spinal range of motion
- Walk (inspect gait)
Have patient sit again, make sure that the patient is comfortable
“That completes the test, do you have any questions or concerns that I have to know about?
Thank you very much and have a great day”