Nursing Head-to-Toe Assessment Notes

Introduction

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Head Assessment

• Orientation:
  • Assess alertness and orientation to person, place, time, and situation.
  • Questions: Ask client their name, current location, date/year, and reason for hospital visit.
  • Document as AO x 4 if oriented in all aspects.
• Eyes:
  • Use a penlight to check if pupils are equal, round, reactive to light and accommodation (PERLA).
  • Check sclera and conjunctiva for abnormalities.
• Nose and Sinuses:
  • Palpate sinuses and inspect nares for patency and ability to breathe.
• Mouth:
  • Inspect lips, oral mucosa, tongue, gums, and teeth for abnormalities.

Neck Assessment

• Lymph Nodes and Thyroid:
  • Palpate for any abnormal nodules.
• Trachea:
  • Inspect and palpate for symmetry, assess ability to swallow, airway patency, and range of motion.
• Jugular Venous Distension (JVD):
  • Inspect for JVD presence.
• Carotid Arteries:
  • Auscultate with the bell of the stethoscope while the client holds their breath.
  • Listen for bruits which are abnormal swooshing sounds.

Chest Assessment

• Heart:
  • Use diaphragm of stethoscope to auscultate 5 heart areas: aortic, pulmonic, Erb's point, tricuspid, and mitral.
  • Check apical pulse and note abnormalities like murmurs.
• Lungs:
  • Observe chest expansion and respiratory rate.
  • Use diaphragm to auscultate lungs; compare left and right sides.
  • Important landmarks: above clavicle (apex), 2nd and 4th intercostal spaces, 6th intercostal space (bases).
  • Posterior thorax auscultation from above scapula to midline T3 to T10.
  • Listen to full inspiration and expiration cycle, document abnormalities.

Abdominal Assessment

• Inspection:
  • Visibly check for abnormalities or distension.
• Auscultation:
  • Use diaphragm to listen to bowel sounds in all four quadrants for at least one minute.
  • Note if sounds are normal, hyperactive, hypoactive, or absent.
  • For absent sounds, listen for 3-5 minutes.
• Palpation:
  • Use gentle palpation for abnormalities like muscle guarding, rigidity, or masses.
  • Palpate clockwise, lifting fingers between locations.
  • Inquire about bowel habits and last bowel movement.

Extremities Assessment

• Examination:
  • Check extremities for deformity, skin abnormalities, symmetry, and edema.
• Palpation:
  • Look for tenderness, soft tissue swelling, and joint effusions.
• Vasculature:
  • Examine capillary refill and palpate pulses on arms, legs, and feet.
• Range of Motion:
  • Test each joint's motion in all directions, note abnormalities.
• Muscle Strength and Tone:
  • Grade strength on a scale of 0 to 5.
  • Observe gait and document.
• Diabetic Foot Care:
  • Examine toes for ulcerations or cuts, document findings.

Conclusion

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