Head to Toe Assessment

DO IT! SAY IT!

Gather Equipment Enter Room, wash hands

1. Good morning, my name is “Student” & I’m am going to be your student nurse today. How are you doing? 2. Pull Curtain closed * Can you tell me your name and date of birth (match it to the wrist band) * I have reviewed your health history and I see you have already changed to a gown, have you been able to provide a urine specimen? * I am going to do a head to toe assessment on you, this will assess your body systems and their functions During this assessment I am going to ask you some questions, inspect, touch, and listen with my stethoscope to different areas of your body. If you have any questions now or throughout the assessment, please feel free to ask questions and if at any time I make you feel uncomfortable, please let me know. Do you have any questions before we begin?

Level of consciousness * Can you tell me where you are and why you are here? * Can you tell me what day it is? **Patient is alert & oriented x 4 to self, place, time, & situation
Observe posture, body movements NV and V speech and expressions, mood, expressions **Body posture, speech, NV and verbal communication is appropriate for the situation. Based on conversation mood, feelings and expressions/perceptions are appropriate for this patient. Patient understands current situation at hand.

Pain * Are you in or feeling any pain right now? No – proceed
*If yes, ask about the pain, location, intensity, type of pain.

Skin * Inspect Color – Skin color is appropriate for patient’s ethnicity * Inspect Tone – Even skin tone throughout * Palpate Temp – Warm skin, afebrile to touch (Palpate skin with back of hand) * Palpate Moisture – Skin is dry with no signs of diaphoresis * Test Elasticity/Turgor – Skin is elastic with good turgor * Palpate for edema – No evidence of edema * Check for lesions – No evidence of lesions (if so use ABCDE)

Nails * Check color, shape and contour – Nails are well groomed, with pink nail beds, no ridges * Check for Spooning – No signs of spooning or iron deficiency * Check for Splinter Hemorrhages – No signs of splinter hemorrhages or infective endocarditis * Check for Clubbing, visual and Shamroth – No evidence of clubbing or chronic hypoxia * Check capillary refill – Patient shows capillary refill in less than two seconds

Head * Inspect head for size, contour – Head size is appropriate for patient * Inspect Hair – Hair is intact, brown in color, thick and well groomed. No evidence of nits, thinning or irregular distribution * Inspect for symmetry and ptosis – Pt’s features are symmetrical, and show no signs of ptosis or evidence of Bell’s Palsy or Stroke * Check alignment – Pinnae and Canthus are aligned showing no evidence of Downs * Check tics – Patient has no ticks or abnormal ocular movement * Check Temp Artery – Arteries are elastic, smooth and palpable. No tenderness * Listen to temp artery – No evidence of bruit * Check TMJ – No sign of crepitus or TMJ syndrome. Smooth movement occurs.

Neck * Perform ROM tests – Pt demonstrates full ROM w/o pain or tenderness * Check Trachea – Trachea is felt at the midline of the neck * Check thyroid/Swallow – Thyroid is nonpalpable, no apparent nodes or masses are felt

Lymphatics * Palpate lymph nodes – Lymph nodes are not palpable, no evidence of enlargement (pre, post, occ, tons, submand, submen)

Exit * I would make sure that the rooms clean * I would make sure that the path to the bathroom is clear * Getting ready to leave room * I would make sure the patient is in a comfortable position * Make sure the bed is in the lowest position with side rails up * I would place the call light and any personal items in reach. * Ask patient if they need anything * Thank them * Preform hand hygiene * Exit Room

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