Nursing Head-to-Toe Assessment

Introduction

• Presented by Sarah from RegisteredNurseRN.com.
• Objective: Perform a nursing head-to-toe assessment similar to clinical check-offs in nursing school.
• Tailor assessments to patient's needs in practice; process becomes faster with experience.

General Process

• Order for systems assessment:
  • Inspect
  • Palpate
  • Percuss
  • Auscultate
• Exception for abdomen:
  • Inspect
  • Auscultate
  • Percuss
  • Palpate
• Reason: Palpation and percussion can alter bowel sounds if done before auscultation.

Preparation

• Perform hand hygiene and ensure patient privacy.
• Introduce yourself and explain the procedure to the patient.
• Verify patient identity through armbands and confirm their name and date of birth.
• Assess neurostatus by asking orientation questions.

Vital Signs

• Collect: Heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and pain rating.
• Assess emotional status, skin color, hygiene, posture, and immediate physical abnormalities.

Head Assessment

Inspection

• Check skin color, head size relative to body, symmetrical facial features.
• Test cranial nerve 7 (facial nerve): Eye closure, smile, frown, puff cheeks.
• Inspect for involuntary movements.

Palpation

• Check for masses, indentations, skin breakdown, and infestations.

Temporal Artery & Cranial Nerve 5

• Palpate temporal artery.
• Test mastication muscle and resistance.

Eye Assessment

• Inspect eyelids, sclera, iris, pupil, and conjunctiva.
• Check for strabismus and anisocoria.
• Test cranial nerves: 3 (oculomotor), 4 (trochlear), 6 (abducens).
  • Six cardinal fields of gaze.
  • Pupillary light reflex.
  • Accommodation.

Ear Assessment

• Inspect external ear for abnormalities.
• Palpate for tenderness.
• Inspect tympanic membrane with otoscope.
• Test cranial nerve 8 (vestibulocochlear nerve) using a whisper test.

Nose Assessment

• Inspect for symmetry and patency.
• Check septum for deviation.
• Test cranial nerve 1 (olfactory nerve) for sense of smell.

Mouth Assessment

• Inspect lips and inside the mouth for sores, color, and moisture.
• Test cranial nerve 12 (hypoglossal nerve).
• Check cranial nerve 9 (glossopharyngeal) and 10 (vagus) through uvula movement and gag reflex.

Neck Assessment

• Inspect trachea alignment.
• Test cranial nerve 11 (accessory nerve).
• Check for jugular venous distension.
• Palpate lymph nodes and trachea.
• Palpate carotid artery; auscultate for bruits.

Upper Extremities

• Inspect for lesions and swelling.
• Palpate radial and brachial pulses.
• Check capillary refill and skin turgor.
• Test muscle strength and joint movement.

Chest Assessment

• Inspect breathing effort and anterior-posterior diameter.
• Auscultate heart sounds at five key locations.
• Listen to lung sounds anteriorly and posteriorly for abnormalities.

Abdominal Assessment

• Inspect contour and any visible pulsations.
• Auscultate bowel sounds and vascular sounds.
• Palpate lightly and deeply for masses or tenderness.

Lower Extremities

• Inspect for color, hair growth, and swelling.
• Palpate pulses and check for edema.
• Test capillary refill and muscle strength.
• Check Babinski reflex.

Back Assessment

• Inspect for moles, lesions, and skin breakdown.

Conclusion

• Detailed walkthrough of a comprehensive head-to-toe assessment.
• Encouragement to explore further resources for nursing success, including videos and reviews for exams like NCLEX.