HEAD TO TOE ASSESSMENT

EYES

1. Determine function
 Vision using Snellen chart – 20/20 without corrective lenses
 Visual fields – confrontation test
 Corneal light reflex reflection of light should be level
 Cover test – eyes should remain fixed
 Cardinal fields – eye movement should be smooth and symmetric
2. External eye
 Position and alignment eyeball – symmetrically aligned
 Bulbar conjunctiva and sclera – clear, moist, and smooth in the sockets
 Cornea, lens, – cornea is transparent
3. Pupillary reaction – eyes constricted
4. Accommodation – constriction

EARS

1. Inspect the auricle, tragus, and lobule - Ears are equal in size bilaterally
2. Palpate the auricle and mastoid process - Normally the auricle, tragus, and mastoid process
are not tender
3. Inspect the external auditory canal - A small amount of odorless cerumen (earwax) is the
only discharge normally present
4. Perform the whisper test - Able to correctly repeat the two-syllable word as whispered.
5. Weber’s test - Vibrations are heard equally well in both ears
6. Rinne test Air conduction sound is normally heard longer than bone conduction sound

NOSE AND SINUSES

1. color, shape, consistency, and tenderness - Color is the same as the rest of the face; the
nasal structure is smooth and symmetric; the client reports no tenderness
2. Check patency of air flow through the nostril - Client is able to sniff through each nostril
while other is occluded.
3. TEST CN1

MOUTH

1. Inspect the lips - Lips are smooth and moist without lesions or swelling
2. Inspect the teeth and gums - No decayed areas; no missing teeth, jaw are aligned, color and
consistency along checks and gums are even
3. Inspect the buccal mucosa - In all clients, tissue is smooth and moist without lesions
4. Assess the uvula - Midline elevation of uvula and symmetric elevation of the soft palate.
5. Inspect for color, moisture, size, and texture - Tongue should be pink, moist, a moderate size
with papillae (little protuberances) present. No lesions are present.
6. Assess the ventral surface of the tongue - The tongue’s ventral surface is smooth, shiny,
pink, or slightly pale, with visible veins and no lesions.
7. Check strength of tongue

NECK

1. Inspect the neck - Neck is symmetric, with head centered and without bulging masses.
 2. Inspect range of motion - Inspect range of motion
3. Palpate the trachea – trachea is midline

ARMS, HANDS, AND FINGERS

1. Inspect the upper extremities for overall skin coloration, texture, masses, and lesions
2. Test CN XI
3. Palpate shoulders and arms for tenderness, swelling, and temperature
4. Test ROM of the elbows
5. Palpate brachial, radial, and ulnar pulse
6. Test ROM of the wrist
7. Inspect palms and palpate for temperature
8. Test ROM of the fingers
9. Test rapid alternating movements
10. Test sensations: light sensation, sensitivity of position, stereognosis, graphesthesia

POSTERIOR AND LATERAL CHEST

1. Inspect configuration and shape of scapulae and chest wall – scapulae are symmetric and
nonprotruding
2. Note the use of accessory muscle
3. Palpate for tenderness and lesions
4. Evaluate chest expansion
5. Percuss for tone at posterior intercostal spaces – resonance is the percussion tone
6. Auscultate for breath sounds

ANTERIOR CHEST

1. Inspect shape and configuration, position of sternum, and slope of ribs

2. Note quality and pattern or respiration
3. Watch sternal retractions
4. Palpate for tenderness, masses, lesions, and chest expansion
5. Percuss for tone
6. Auscultate breath sounds
7. Pinch skin over sternum

FEMALE BREASTS

1. Inspects size, symmetry, color, texture, areolas, and nipples

2. Inspect for retractions and dimpling of nipples
3. Palpate each breast, areola, and nipples
4. Palpate axillae for rashes and lesions

MALE BREATS

1. Inspect for swelling, nodules

2. Palpate the axillae

HEART

1. Inspect and palpate for apical impulse

2. Palpate apical impulse for any abnormal pulsations
3. Auscultate hr and rhythm, s1 and s2, and murmurs
ABDOMEN

1. Inspect for overall skin color, lesions, and rashes

2. Location and color of umbilicus
3. Inspect for symmetry
4. Auscultate for bowel sounds
5. Percuss for tone over four quadrants
6. Palpate for masses and deep palpation

LEGS, FEET, AND TOES

1. Inspect lower extremities for skin color, texture, masses, and lesions
2. Note hair distribution
3. Palpate for edema and temperature
4. Palpate knees including popliteal pulse
5. Assess capillary refill
6. Test sensation, position sense, and heel to shin

MUSCULOSKELETAL

1. Observe gait
2. Hop in one leg
3. Finger to nose test
4. Romberg test

MALE GENETALIA

1. Inspect the penis including the base and pubic hair distribution, skin and shaft for any
rashes, lesions, lumps and tender areas, color, and locations
2. Palpate for urethral discharges
3. Inspect scrotum
4. Palpate both testes for size, shape, and tenderness

FEMALE GENETALIA

1. Inspect for hair distribution, mons pubis, labia majora for lesions and swelling
2. Inspect labia minora and vaginal opening for lesions, swelling, and discharges
3. Palpate vaginal opening
4. Inspect cervix for lesions and discharges