Head to Toe Assessment NUR 201 Fall 2018 Jensen

First – introduce yourself and role, the exam process. Observe general appearance, position in bed, skin color, breathing,
name band, lighting, call bell, equipment, fall risk.
Second – remember – you need to focus your assessment to your patient and talk with him or her. Wash hands and glove
as appropriate; only uncover what you are examining (remember privacy, warmth).

Not Comments
done
HEENT: 2: Performed
 Assess mental status (LOC, A & O x3, follow simple commands) correctly
 Inspect for hearing and vision (read newsprint, functional hearing, any assistive 1: Needs more
devices?) practice
 Inspect skin, head, facial movements, PERRLA . lights on. 0: skill not
 Inspect conjunctiva, sclera performed
 Inspect oropharynx (condition, uvula rises)
Neck:
 Inspect skin, trachea, neck vein distention (JVD), carotid pulses (feel for thrill),
ROM, strength
Upper extremities:
 Inspect arms, hands, skin, nails, joints.
 Circulation bilateral compare symmetry (color, temp, cap refill, radial pulses),
Movement (strength /grasp, ROM), Sensation (to touch, paresthesia).
Anterior chest:
 Inspect chest wall diameter, movement
 Auscultate breath sounds – compare sides; note normal, abnormal or
adventitious sounds
 Auscultate heart sounds –Erb point, for rate, rhythm, S1 S2, extra sounds,
murmurs. One minute.
 Note any shortness of breath, sputum, cough
Abdomen:
 Inspect abdomen shape, color, scars, movement
 Auscultate bowel sounds all four quads. Percuss abdomen all 4 quadrants.
 Lightly palpate for tenderness, masses all 4 quadrants. Deep if indicated.
 Assess appetite. Last BM? Last voiding?
Lower extremities:
 Inspect skin, legs,joints, feet, between toes, nails. Assess edema
 Circulation symmetrical (color, temp, cap refill, dorsalis pedis pulses),
Movement (strength /resistance, ROM) Sensation (to touch, paresthesia)
Posterior chest, back:
 Inspect breathing, shape, skin
 Auscultate breath sounds and apex to bases, 10 locations
 Inspect lower back (skin, alignment, redness, edema)
 Inspect spine, sacrum, pressure points if immobile
Standing:
 Balance, transfer, gait, coordination
Closure
Summarize findings for patient. Does this sound accurate? Do you have any concerns?
Assess room for safety (bedside table, lights, call light, toileting) . Share initial plan of care.
Is there anything else I can do? Close interview.
 Head to Toe Assessment
NUR 201 Fall 2018 Jensen

Student Last Name , First (Print) ________________________________________________ Week of Nov 26 2018

Assessments Met 2 Improvements Communication,

-Not Met organization,
1-0 confidence,
accuracy
1.Introduce self to client using therapeutic communication, proper
hand hygiene, Identify client by name band & name with two
identifiers.

2. HEENT, Neck

3. Upper extremities

4. Anterior chest lungs, heart

5. Abdomen

6. Lower extremities.

7. Posterior chest, lungs, spine

8 . Standing, gait

9. Confident, efficient, organized, accurate, clear communication.

Talks to patient, privacy and draping. Provides comfort.

10. Disposes of equipment and washes hands, plan, closure. Safety

check. Completed within 15-20 minutes.

FINAL SCORE TOTAL 20 POINTS

(19=95%, 18=90%, 17=85%, 16=80%, 15=75%, 14=7-%, 13=65%,
12=60%, 11=55%, 10=50%)

FINAL PERCENTAGE________________

Comments

Instructor_______________________________Date________________
 Head to Toe Assessment NUR 201 Fall 2018 Jensen

First – introduce yourself and role, the exam process. Observe general appearance, position in bed, skin color, breathing,

name band, lighting, call bell, equipment, fall risk.

Second – remember – you need to focus your assessment to your patient and talk with him or her. Wash hands and glove

as appropriate; only uncover what you are examining (remember privacy, warmth).

Gather equipment, prepare yourself

HEENT:

 Assess mental status (LOC, A & O x3, follow simple commands)

 Inspect for hearing and vision (read newsprint, functional hearing, any assistive devices?)

 Inspect skin, head, facial movements, PERRLA . lights on.

 Inspect conjunctiva, sclera

 Inspect oropharynx (condition, uvula rises)

Neck:

 Inspect skin, trachea, neck vein distention (JVD), carotid pulses (feel for thrill), ROM, strength

Upper extremities:

 Inspect arms, hands, skin, nails, joints.

 Circulation bilateral compare symmetry (color, temp, cap refill, radial pulses), Movement (strength

/grasp, ROM), Sensation (to touch, paresthesia).

Anterior chest:

 Inspect chest wall diameter, movement

 Auscultate breath sounds – compare sides; note normal, abnormal or adventitious sounds

 Auscultate heart sounds –Erb point, for rate, rhythm, S1 S2, extra sounds, murmurs. One minute.

 Note any shortness of breath, sputum, cough

 Abdomen:

 Inspect abdomen shape, color, scars, movement

 Auscultate bowel sounds all four quads. Percuss abdomen all 4 quadrants.

 Lightly palpate for tenderness, masses all 4 quadrants. Deep if indicated.

 Assess appetite. Last BM? Last voiding?

Lower extremities:

 Inspect skin, legs,joints, feet, between toes, nails. Assess edema

 Circulation symmetrical (color, temp, cap refill, dorsalis pedis pulses), Movement (strength

/resistance, ROM) Sensation (to touch, paresthesia)

Posterior chest, back:

 Inspect breathing, shape, skin

 Auscultate breath sounds and apex to bases, 10 locations

 Inspect lower back (skin, alignment, redness, edema)

 Inspect spine, sacrum, pressure points if immobile

Standing:

 Balance, transfer, gait, coordination

Closure

Summarize findings for patient. Does this sound accurate? Do you have any concerns?

Assess room for safety (bedside table, lights, call light, toileting) . Share initial plan of care.

Is there anything else I can do? Close interview.