Complete Head-to-Toe Physical Assessment

Cheat Sheet
By Matt Vera, BSN, R.N. - February 18, 2012

Nursing assessment is an important step of the whole nursing process. Assessment can be
called the “base or foundation” of the nursing process. With a weak or incorrect assessment,
nurses can create an incorrect nursing diagnosis and plans therefore creating wrong
interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet
that you can print and use to guide you throughout the rst step of the nursing process.

SEE ALSO: Nursing Health Assessment Mnemonics & Tips

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Physical Assessment

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 ngers (Blanch Test), the nails
return to usual color in less than 4 seconds.

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 at 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 eld, the client can see objects in the periphery when
looking straight ahead.
When testing for the Extraocular 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

Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are
aligned with the outer canthus of eye. When palpating for the texture, the auricles are mobile,
rm and not tender. The pinna recoils when folded. During the assessment of Watch tick test,
the client was able to hear ticking in both ears.

Nose and Sinus

 Nose: The nose appeared symmetric, straight and uniform in color. There was no presence of
discharge or aring. When lightly palpated, there were no tenderness and lesions
Mouth:
The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The
client was able to purse his lips when asked to whistle.
Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish
in color of gums
The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with
elastic texture.
The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough.
There is a presence of thin whitish coating.
The smooth palates are light pink and smooth while the hard palate has a more irregular
texture.
The uvula of the client is positioned in the midline of the soft palate.
Neck:
The neck muscles are equal in size. The client showed coordinated, smooth head movement
with no discomfort.
The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the glands ascend during swallowing but
are not visible.

Thorax, Lungs, and Abdomen

Lungs / Chest: The chest wall is intact with no tenderness and masses. There’s a full and
symmetric expansion and the thumbs separate 2-3 cm during deep inspiration when assessing
for the respiratory excursion. The client manifested quiet, rhythmic and e ortless respirations.
The spine is vertically aligned. The right and left shoulders and hips are of the same height.
Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence
of heaves or lifts.
Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The
abdomen has a symmetric contour. There were symmetric movements caused associated with
client’s respiration.
The jugular veins are not visible.
When nails pressed between the ngers (Blanch Test), the nails return to usual color in less
than 4 seconds.

Extremities

The extremities are symmetrical in size and length.

Muscles: The muscles are not palpable with the absence of tremors. They are normally rm
and showed smooth, coordinated movements.
Bones: There were no presence of bone deformities, tenderness and swelling.
Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form

Assessment Findings
Integumentary
Assessment Findings
When skin is pinched it goes to previous state
immediately (2 seconds).
Skin
With fair complexion.
With dry skin
Evenly distributed hair.
Hair With short, black and shiny hair.
With presence of pediculosis Capitis.
Smooth and has intact epidermis
With short and clean ngernails and toenails.
Nails
Convex and with good capillary re ll time of 2
seconds.
Rounded, normocephalic and symmetrical,
Skull smooth and has uniform consistency.Absence
of nodules or masses.
Symmetrical facial movement, palpebral
Face ssures equal in size, symmetric nasolabial
folds.
Eyes and Vision
Hair evenly distributed with skin intact.
Eyebrows Eyebrows are symmetrically aligned and have
equal movement.

Equally distributed and curled slightly

Eyelashes
outward.

Skin intact with no discharges and no

discoloration.
Eyelids
Lids close symmetrically and blinks
involuntary.

Bulbar conjunctiva Transparent with capillaries slightly visible

Palpebral Conjunctiva Shiny, smooth, pink

Sclera Appears white.

Lacrimal gland, Lacrimal sac, Nasolacrimal No edema or tenderness over the lacrimal
duct gland and no tearing.

Cornea
Transparent, smooth and shiny upon
inspection by the use of a penlight which is
Clarity and texture held in an oblique angle of the eye and
moving the light slowly across the eye.
Has [brown] eyes.

Blinks when the cornea is touched through a

Corneal sensitivity
cotton wisp from the back of the client.
Assessment Findings
Black, equal in size with consensual and direct
reaction, pupils equally rounded and reactive
to light and accommodation, pupils constrict
Pupils when looking at near objects, dilates at far
objects, converge when object is moved
toward the nose at four inches distance and
by using penlight.
When looking straight ahead, the client can
see objects at the periphery which is done by
having the client sit directly facing the nurse at
a distance of 2-3 feet.
Visual Fields
The right eye is covered with a card and asked
to look directly at the student nurse’s nose.
Hold penlight in the periphery and ask the
client when the moving object is spotted.
Able to identify letter/read in the newsprints
at a distance of fourteen inches.
Visual Acuity
Patient was able to read the newsprint at a
distance of 8 inches.
Ear and Hearing
Color of the auricles is same as facial skin,
symmetrical, auricle is aligned with the outer
Auricles
canthus of the eye, mobile, rm, non-tender,
and pinna recoils after it is being folded.

External Ear Canal Without impacted cerumen.

Hearing Acuity Test Voice sound audible.

Able to hear ticking on right ear at a distance

Watch Tick Test
Nose and sinuses
External Nose
of one inch and was able to hear the ticking
on the left ear at the same distance
Symmetric and straight, no aring, uniform in
color, air moves freely as the clients breathes
through the nares.

Mucosa is pink, no lesions and nasal septum

Nasal Cavity
intact and in middle with no tenderness.

Symmetrical, pale lips, brown gums and able

Mouth and Oropharynx
to purse lips.

Teeth With dental caries and decayed lower molars

Central position, pink but with whitish coating

Tongue and oor of the mouth which is normal, with veins prominent in the
oor of the mouth.
Assessment Findings

Moves when asked to move without di culty

Tongue movement
and without tenderness upon palpation.

Uvula Positioned midline of soft palate.

Present which is elicited through the use of a
Gag Re ex
tongue depressor.
Positioned at the midline without tenderness
Neck
and exes easily. No masses palpated.
Coordinated, smooth movement with no
Head movement discomfort, head laterally exes, head laterally
rotates and hyperextends.
Muscle strength With equal strength
Lymph Nodes Non-palpable, non tender
Not visible on inspection, glands ascend but
Thyroid Gland not visible in female during swallowing and
visible in males.
Thorax and lungs
Posterior thorax Chest symmetrical
Spine vertically aligned, spinal column is
Spinal alignment straight, left and right shoulders and hips are
at the same height.
Breath Sounds With  normal breath sounds without dyspnea.

Anterior Thorax Quiet, rhythmic and e ortless respiration

Unblemished skin, uniform in color,

Abdomen
symmetric contour, not distended.
Symmetrical movements cause by
Abdominal movements
respirations.

With audible sounds of 23 bowel

Auscultation of bowel sounds
sounds/minute.

Upper Extremities Without scars and lesions on both extremities.

Lower Extremities With minimal scars on lower extremities
Equal in size both sides of the body, smooth
Muscles coordinated movements, 100% of normal full
movement against gravity and full resistance.
No deformities or swelling, joints move
Bones and Joints
smoothly.
Mental Status
Language Can express oneself by speech or sign.
Orientation Oriented to a person, place, date or time.
Able to concentrate as evidence by answering
Attention span
the questions appropriately.
A total of 15 points indicative of complete
Level of Consciousness
orientation and alertness.
Motor Function
 Assessment Findings
Gross Motor and Balance
Has upright posture and steady gait with
Walking gait opposing arm swing unaided and maintaining
balance.
Standing on one foot with eyes closed Maintained stance for at least ve (5) seconds.
Maintains a heel toe walking along a straight
Heel toe walking
line
Toe or heel walking Able to walk several steps in toes/heels.
Fine motor test for Upper Extremities
Repeatedly and rhythmically touches the
Finger to nose test
nose.
Alternating supination and pronation of hands Can alternately supinate and pronate hands at
on knees rapid pace.
Finger to nose and to the nurse’s nger Perform with coordinating and rapidity.
Fingers to ngers Perform with accuracy and rapidity.
Rapidly touches each nger to thumb with
Fingers to thumb
each hand.
Fine motor test for the Lower Extremities
Able to discriminate between sharp and dull
Pain sensation sensation when touched with needle and
cotton.

Last updated on February 11, 2019

Matt Vera, BSN, R.N.

https://nurseslabs.com

Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and
editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on di cult nursing topics and nding
 help online is near to impossible. His situation drove his passion for helping student nurses through the creation of content and
lectures that is easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to
educate and inspire students in nursing. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process,
breakdown complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing
concepts e ectively.

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