HEAD TO TOE ASSESSSMENT
GENERAL APPEARANCE & MENTAL STATUS
Observe for signs of distress in posture or facial
expression.
Observe body build, height, and weight in relation to the
client’s age, lifestyle, and
Observe client’s posture and gait, standing, sitting, and He has a normal posture in terms of standing,
walking.
Observe client’s overall hygiene and grooming.
Note body and breath odor.
Note obvious signs of health or illness.
Assess the client’s attitude.
Note the client’s affect/mood; assess the appropriateness The client has a good attitude. All his answers are
of the client’s responses.
Listen for quantity, quality, and organization of speech The client’s way of speaking is clear/the quality of
SKIN
Inspect skin color.
Inspect uniformity of skin color.
Inspect, palpate, and describe skin lesions.
Observe and palpate skin moisture.
Palpate skin temperature.
Palpate to assess for presence of edema.
Palpate to assess for skin turgor.
HAIR
Inspect the evenness of growth over the scalp.
Inspect hair thickness or thinness.
Inspect hair texture and oiliness.
Note presence of infections or infestations.
Inspect amount of body hair.
NAILS
Inspect fingernail plate shape.
Inspect fingernail and toenail bed color.
Inspect tissues surrounding nails.
Palpate fingernail and toenail texture.
FINDINGS
He has a good posture and a good facial
expression.
He is a little bit fat and he is tall.
sitting and walking. No problem seen.
He is neat. Overall hygiene and grooming are
good.
Normal body odor and breath odor.
No signs of health or illness.
He is cooperative and very jolly. He answers all
the questions politely.
facts.
his voice is clear. He is well spoken.
The client’s skin color is tan.
Generally uniform except for areas exposed to sun;
areas of lighter pigmentation in dark skinned.
No skin lesions present.
As I have observed, the client skin is slightly dry.
The client’s skin temperature is within the normal
range.
No presence of edema.
The client is hydrated since the client’s skin
returns to its normal position for a second.
The client’s hair is evenly distributed.
He has a thick and short hair.
The hair is smooth and a little bit oily.
No presence of infections or infestations seen.
No abnormalities seen.
The client’s fingernail plate shape is within the
normal range. No clubbing is present.
Smooth and pinkish in color.
As I inspect, the client’s tissues surrounding nails
is within the normal range.
The client’s fingernail and toenail texture are soft
and flexible.
 Perform blanch test of capillary refill. The client is hydrated since after a second it
returns to its normal position.

HEAD TO NECK FINDINGS

HEAD & FACE
Inspect the head. The size of the head is appropriate to the client’s
body.
Palpate the head The head is symmetrical.
Palpate the temporal artery Temporal artery of the client is within the normal
range.
Palpate the temporomandibular joint (TMJ). Condylar movement were easily felt by the client
which is in the normal state.
NECK
Inspect the neck. No scars are present in the neck and no nodal
enlargement present.
Inspect movement of the neck structures Neck flexion is within the normal range since the
motion is from 40-80 degrees.
Inspect the cervical vertebrae. The cervical vertebrae of the client are within the
normal state.
Inspect range of motion. The range of motion of the client is within a normal
range since it is from 40-80 degrees.
Palpate the trachea. No abnormalities were seen in the trachea.
Palpate the thyroid gland. The thyroid gland was palpable and rises along with
thyroid and cricoid cartilage during swallowing.
Palpate the lymph nodes. It was soft, smooth, movable, non-tender and bean-
shaped structures. That’s why the client is within the
normal range.
EYES
Test distant visual acuity. The client distant visual acuity is within the normal
range.
Test near visual acuity. The client near visual acuity is within the normal
range.
Test visual fields for gross peripheral vision. The visual fields for gross peripheral vision of the
client is within the normal range.
Inspect the eyelids and eyelashes. The eyelashes were evenly distributed.
Assess ability of eyelids to close. The client’s eyelids ability to close is within the
normal state.
Note the position of the eyelids in comparison with the It is within the normal state.
eyeballs.
Observe eyelids for redness, swelling, discharge or No swelling or lesions present.
lesions.
Observe eyelids for the position and alignment of the The alignment of the eyeball in the eye socket for the
eyeball in the eye socket. eyelids is compatible and no abnormalities were seen.
Inspect the bulbar conjunctiva and sclera. The sclera is white in color and the bulbar conjunctiva
is within the normal range.
Inspect the palpebral conjunctiva. The palpebral conjunctiva is pink in color.
Inspect the lacrimal apparatus. The lacrimal apparatus of the client is within the
normal range.
Palpate the lacrimal apparatus. No tenderness on palpation and it is non-palpable.
Inspect the cornea and lens. Cornea is translucent, smooth and avascular.
Inspect the iris and pupil. Iris is flat and color varies. The pupil dilates in the
dark.
Test pupillary reaction to light (Pupillary Light The pupil constricts when the light is directed to it.
Reflex).
Assess Consensual Response It changed in pupil size in the eye to which the light is
directed.
Test accommodation of pupils. The pupil constricts while fixating on an object being
moved from far away to near the eye.
EARS
Inspect the auricle, tragus and lobule. The shape and the size are within the normal range.
Palpate the auricle and mastoid process The auricle and mastoid process is within the normal
range.
Perform whisper test The client responds correctly.
Perform Weber’s Test The client reports the sound heard equally both sides.
Perform the Rinne’s Test The client was able to hear the sound of tuning fork.
Perform the Romberg Test The client is within the normal state.
MOUTH & THROAT
Inspect the lips. The lip is pinkish in color and is not dry.
Inspect the teeth and gums The teeth were white and complete and the gums is
pinkish in color.
Inspect the buccal mucosa. No abnormalities were seen in the buccal mucosa.
Inspect and palpate the tongue. The tongue is pinkish in color and he can move his
tongue.
Assess the ventral surface of the tongue The ventral surface of the tongue has a smooth
surface. The tongue is fitted comfortably in the
client’s mouth.
Inspect for Wharton’s ducts No abnormalities were seen.
Observe the sides of the tongue. The sides of the tongue have a rough dorsal surface
due to papillae.
Check the strength of the tongue. The client’s tongue is strong.
Inspect the hard (anterior) and soft (posterior) palates It was in the normal range.
and uvula.
Note odor while the mouth is wide open The odor is good and normal.
Assess the uvula No abnormalities in the uvula is present.
Inspect the tonsils Symmetrical and is in normal size.
Inspect the posterior pharyngeal wall The posterior pharyngeal wall of the client is within
the normal range.
NOSE
Inspect and palpate the external nose The external nose was palpable and no abnormalities
were seen.
Check patency of airflow through the nostrils The airflow through the nostrils were good.
Inspect the internal nose The internal nose has its hair and it was in the normal
range.
SINUSES
Palpate the sinuses
Percuss the sinuses
CHEST, BREAST, HEART
POSTERIOR THORAX
Inspect Configuration
Observe use of accessory muscles
Inspect the client’s positioning
Palpate for tenderness, sensation and crepitus
Palpate surface characteristics
Palpate for fremitus
Assess chest expansion
Percuss the tone
Percuss for diaphragmatic excursion
Auscultate for breath sounds
Auscultate for voice sounds
ANTERIOR THORAX
Inspect for shape and configuration
Inspect position of the sternum
Watch for sternal retractions
Inspect slope of the ribs
Observe quality and pattern of respirations
Inspect intercostal spaces
Observe for use of accessory muscles
Palpate for tenderness, sensation and surface No tenderness or pain is palpated.
masses
Palpate for tenderness at costochondral Palpation does not elicit tenderness.
junctions of ribs
Palpate for crepitus
Palpate for fremitus
Sinuses are within the normal range.
In percussing the sinuses, no abnormalities are
present.
FINDINGS
Scapulae are symmetric and non-protruding.
Shoulders and scapulae are at equal horizontal
positions. Overall, no abnormalities were
present.
The client does not use accessory muscle to
assist breathing. The diaphragm is the major
muscle at work.
Client is sitting up and relaxed with a good
posture. He also breaths easily with the arms
on his side.
No tenderness, pain, or unusual sensations.
Skin and subcutaneous tissue are free of
lesions and masses.
Fremitus remain symmetric for bilateral
positions.
The client’s thumb moves 5 to 10cm apart
symmetrically as the client takes deep breath.
Resonance elicited over lung tissue.
Excursion measure 5cm.
Bronchial and vesicular are auscultated.
No adventitious sounds are auscultated.
No abnormalities were present.
Sternum is positioned at midline and straight.
Retractions were not seen.
The slope of the ribs is at normal state.
Respirations are relaxed, effortless, and quiet.
No retractions or bulging of intercostal spaces
are noted.
Use of accessory muscles is not seen with
normal respiratory effort.
No crepitus is palpated.
Fremitus are symmetric bilaterally.
Palpate anterior chest expansion
Percuss the tone
Auscultate for breath sounds
BREASTS & LYMPHATIC SYSTEM
Inspect size and symmetry.
Inspect color and texture.
Inspect superficial venous pattern.
Inspect the areolas.
Inspect the nipples.
Inspect for retraction and dimpling.
Palpate texture and elasticity
Palpate for tenderness and temperature. Breast have normal body temp.
Palpate for masses.
Palpate the nipples.
Inspect and palpate the axillae.
Demonstrate how to perform Breast Self- BSE (Breast Self-Exam) is demonstrated.
Exam
HEART & NECK VESSELS
Observe the jugular venous pulse.
Evaluate jugular venous pressure.
Auscultate the carotid arteries
Palpate the carotid arteries.
Inspect pulsations.
Palpate the apical impulse.
Palpate for abnormal pulsations.
Auscultate heart rate and rhythm.
Auscultate to identify S1 and S2.
Auscultate for extra heart sounds.
Auscultate for murmurs.
The anterior chest expansion is within the
normal range.
Resonance elicited over lung tissue.
Have a normal breath sound.
Size and symmetry is within the normal range.
Light and has smooth texture. No edema is
present.
Veins radiate horizontally and toward the
axilla.
The areolas of the client is within the normal
state. They are round and dark brown in color
and has a smooth texture.
Nipples are nearly equal bilaterally in size.
Breast rise symmetrically and is on normal
state.
Smooth, firm and elastic tissue.
No masses were palpated.
Nipples are erect.
No rash or infection noted.
It is not visible with the client sitting upright.
Not distended, bulging or protruding at 45
degrees or more than.
No blowing or swishing or other sounds heard.
The pulse is equally strong.
The arteries are elastic and no thrills are noted.
Apical impulse is visible in the mitral area.
Palpated in the mitral area and is 1-2cm in
size.
No pulsations or vibrations are palpated in the
area.
Hearth rate and rhythm is within the normal
range.
S1 corresponds w/ each carotid pulsation and
is loudest at the apex of the heart.
S2 immediately follows after S1 and is loudest
at the base of the heart.
No sounds heard.
No sounds heard.
ABDOMEN FINDINGS
Observe the coloration of the skin. The coloration of the skin is tan.
Inspect for scars. No scars present, only moles.
Assess for lesions and rashes. No lesions and rashes were present.
Inspect the umbilicus. The position of the umbilicus of the client is
within the normal state.
Inspect abdominal contour. The abdominal contour of the client is within
the normal state.
Assess abdominal symmetry. It moves posteriorly in a symmetrical fashion.
Inspect abdominal movement when the client It moves in the same direction.
breathes
Observe aortic pulsations. There are no abnormalities observed in the
aortic pulsations.
Observe for peristaltic waves. No abnormalities observed for the peristaltic
waves.
Auscultate for bowel sounds. It is within the normal state since clicks and
gurgles is 5-30 per minute.
Auscultate for vascular sounds. The vascular sounds of the client are within the
normal state.
Auscultate for a friction rub over the liver and It is within the normal state.
spleen.
Percuss for tone. It is within the normal state.
Percuss the span or height of the liver by The span or height of the liver from lower and
determining its lower and upper borders. upper borders are within the normal range.
Deeply palpate all quadrants to delineate No abnormalities present.
abdominal organs and detect subtle masses.
Palpate the liver. It was palpable and soft and smooth and
slightly tender.
Palpate the urinary bladder. It was smooth and firm.
Assess for rebound tenderness. No abnormalities were present.
MUSCULOSKELETAL
Inspect the muscles for size. Compare each
muscle on one side of the body to the same
muscle on the other side.
Inspect the muscles and tendons for contractures.
Inspect the muscles for tremors.
Palpate muscles at rest to determine muscle
tonicity.
Palpate muscles while the client is active and
passive for flaccidity, spasticity, and smoothness
of movement
Test muscle strength of the head & shoulders
Test muscle strength of upper extremities
Test muscle strength of lower extremities
Inspect the skeleton for normal structure and
deformities.
Palpate the bones to locate any areas of edema or
tenderness.
Inspect the joint for swelling.
FINDINGS
The muscle of the client on both sides are
the same and there are no discrepancies
present. No deformity present
The client is within the normal range since
no contractures are observed.
The findings are there is no tremor or
symptom of any uncontrollable rhythm and
fasciculation present in the client’s hands
and arms.
The client is within the usual (normal) range
because the muscles at rest are still relaxed
when I perform the assessment (Range of
Motion).
The client’s movements are coordinated and
there is no sudden involuntary muscle
contraction.
The client is within the normal range, the
same force is found on each side of the
body. Total natural motion 100% against
gravity and maximum resistance.
Based on the muscle strength rating, it is in
grade 5 that is 100% natural muscle strength,
regular free motion against gravity and
maximum resistance. Normal full movement
against full resistance and against gravity.
The client is within the normal range since
the lower extremities do not show any sign
of weaknesses and 100% normal full
movement and muscle strength against
gravity and full resistance.
No evidence of any misaligned bones, no
deformities are present when conducting the
evaluation. The posture and gait of the client
are observed. The bones are in their normal
structure.
The client does not experience any
discomfort when I examine and inspects
from head to toe. There is no tenderness or
edema observed.
There are no swollen joints present. There is
no visible presence of tenderness, swelling,
 crepitation or nodules.
Palpate each joint for tenderness, smoothness of There are no swollen joints present. There is
movement, swelling, crepitation, and presence of no visible presence of tenderness, swelling,
nodules. crepitation or nodules.
Assess joint range of motion of the head The client has a full range of motion. The
client can move her head with no pain or any
barrier.
Assess joint range of motion of body trunk Varies to some degree in accordance with
person’s genetic makeup and degree of
physical activity.
Full range of motion.
Assess joint range of motion of upper extremities The client has a full range of motion. The
client moved his upper extremities fully with
no barriers occurred.
Assess joint range of motion of lower extremities The client is within the normal range,
because she was able to do the ROM
exercises or test without any hesitation and
difficulty.

MEASUREMENTS

Areas to be Norms Actual Analysis & Interpretation

Assessed Findings

Weight Gain 11.5kg-16kg 12 Interpretation:

NORMAL

Cardiac Rate 60-100 bpm 72 bpm Interpretation:

NORMAL

Temperature 36–37.5°C (98–100°F) 36.5°C Interpretation:

NORMAL

Respiratory Rate 12-20 bpm 18 bpm Interpretation:

NORMAL

Blood Pressure systolic: less than 120 mm Hg 90/70 Interpretation:

diastolic: less than 80 mm Hg NORMAL