Nursing Head-to-Toe Assessment Lecture Notes

Introduction

• Presented by Sarah from RegisteredNurseOrient.com
• Demonstration of a nursing head-to-toe assessment
• Similar to clinical checkoff in nursing school
• Practical guide for assessing patients from head to toe

General Assessment Approach

• Sequence: Inspect, palpate, percuss, auscultate (except for abdomen: inspect, auscultate, percuss, palpate)
• Reason: Auscultate abdomen before palpation/percussion to avoid altering bowel sounds

Preparation

• Perform hand hygiene
• Provide patient privacy
• Introduce yourself to the patient
• Confirm patient identity using armband and by asking questions (e.g., name, DOB, location, current events)

Vital Signs & General Observations

• Collect heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, pain rating
• Observe patient’s emotional status, appearance, skin color, hygiene, posture

Head Assessment

Inspection

• Check skin color, head size, symmetry of face, facial movements, eye & ear alignment
• Test cranial nerve 7 (facial expressions)

Palpation

• Check for masses, indentations, skin breakdown (wear gloves)
• Inspect hair and beard for infestations or lesions

Temporal Artery & Cranial Nerve 5

• Palpate temporal arteries and test trigeminal nerve (mastication and jaw movements)

Eye Assessment

• Inspect eyelids, sclera, iris, pupils, conjunctiva for abnormalities
• Check for anisocoria (unequal pupil size)
• Test cranial nerves 3, 4, 6 (ocular movements, nystagmus)
• Assess pupil reaction to light and accommodation

Ear Assessment

• Inspect outer ear, check for pain or abnormalities
• Palpate external ear and mastoid process
• Use otoscope to inspect tympanic membrane
• Test cranial nerve 8 (vestibulocochlear) using whisper test

Nose Assessment

• Inspect for alignment, patency, drainage
• Test cranial nerve 1 (olfactory) with a smell test

Mouth & Throat Assessment

• Inspect lips, inside of mouth, tongue, gums, teeth
• Test cranial nerve 12 (tongue movements)
• Examine uvula and soft palate (test cranial nerve 9 and 10)

Neck Assessment

• Inspect for trachea alignment, lumps, or goiter
• Test cranial nerve 11 (accessory; head & shoulder movements)
• Check for jugular vein distention
• Palpate lymph nodes and carotid artery
• Auscultate carotid artery for bruits

Upper Extremities Assessment

• Inspect for lesions, swelling, assess IV/central lines
• Palpate radial and brachial pulses
• Check capillary refill and skin turgor
• Test muscle strength and joint mobility
• Check for arm drift (neurological assessment)

Chest Assessment

• Inspect chest for lesions, breathing effort, anterior-posterior diameter
• Auscultate heart sounds (aortic, pulmonic, Erb’s point, tricuspid, mitral)
• Auscultate lung sounds for abnormalities

Abdomen Assessment

• Sequence: inspect, auscultate, percuss, palpate
• Inspect for contour, pulsations, hernias, ostomies
• Auscultate bowel sounds and vascular sounds
• Perform light and deep palpation for tenderness or masses

Lower Extremities Assessment

• Inspect color, hair growth, swelling, joint redness
• Palpate popliteal, posterior tibial, and dorsalis pedis pulses
• Check capillary refill, muscular strength, reflexes
• Assess for edema and diabetic foot issues

Back Assessment

• Inspect for lesions, skin breakdown, moles, and listen to lung sounds if not done earlier

Conclusion

• Encouragement to view other educational resources available
• Invitation to subscribe for more nursing content

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Note: Always adapt the assessment to meet the specific needs of your patient, and practice to become more efficient.