Nursing Head-to-Toe Assessment Lecture Notes

Introduction

• Presenter: Sarah from RegisteredNurseRN.com
• Purpose: To demonstrate a head-to-toe nursing assessment, similar to clinical check-offs in nursing school.
• Customization: In practice, nurses will tailor assessments to patient needs and become more efficient.

General Sequence for Systems

1. Inspect
2. Palpate
3. Percuss
4. Auscultate
   • Exception: Abdomen
     • Order: Inspect, Auscultate, Percuss, Palpate
     • Reason: Palpation and percussion first can alter bowel sounds.

Initial Procedures

• Perform hand hygiene.
• Provide privacy.
• Introduce yourself and explain the procedure.
• Verify patient identity by checking the armband and asking questions like:
  • Name, Date of birth, Current location, Activity, and Current events.

Vital Signs & Initial Observations

• Vital Signs: Heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, pain rating (0-10 scale).
• General Observations:
  • Emotional status, skin color, age appearance, communication clarity.
  • Hygiene, posture, any abnormal smells, or visible abnormalities.

Head Assessment

1. Inspection:
   • Check skin color, head size, and symmetry.
   • Look for involuntary movements, facial symmetry (drooping indicates Bell's Palsy/stroke).
   • Eye and ear level.
2. Palpation:
   • Check for masses, indentations, skin breakdown, infestations.
   • Assess beard (if present).
3. Cranial Nerve Tests:
   • CN VII (Facial Nerve): Facial expressions.
   • CN V (Trigeminal Nerve): Clench teeth, jaw resistance.

Eye Assessment

• Inspection: Eyelids, sclera, iris, pupils, conjunctiva, strabismus.
• Cranial Nerves: CN III, IV, VI (Oculomotor, Trochlear, Abducens) through:
  • Nystagmus check using pen light.
  • Pupil reactivity to light and accommodation (PERRLA).

Ear Assessment

• Inspection & Palpation: Outer ear abnormalities, tenderness.
• Otoscope Use: Tympanic membrane inspection.
• Cranial Nerve VIII (Vestibulocochlear): Whisper test.

Nose Assessment

• Inspection: Midline position, septum deviation.
• Patency Test: Verify airflow through each nostril.
• Cranial Nerve I (Olfactory): Smell test.

Mouth & Throat Assessment

• Inspection: Lips, internal mouth, gums, teeth, tongue.
• Cranial Nerve Tests:
  • CN XII (Hypoglossal): Tongue movements.
  • CN IX & X (Glossopharyngeal & Vagus): Uvula movement, gag reflex.

Neck Assessment

• Inspection & Palpation: Trachea alignment, lymph nodes.
• Cranial Nerve XI (Accessory): Head movement, shoulder shrug.
• Jugular Vein Distension: Check at 45-degree angle.

Upper Extremities

• Inspection: Color, lesions, IV sites.
• Palpation: Pulses, capillary refill, skin turgor.
• Muscle Strength: Hand grips, arm resistance.
• Range of Motion & Drift Test.

Chest and Lungs

• Inspection: Breathing effort, AP diameter.
• Heart Auscultation:
  • Locations: Aortic, Pulmonic, Erb's Point, Tricuspid, Mitral.
  • Check for murmurs with bell.
• Lung Auscultation: Crackles, wheezes, friction rub, stridor.

Abdomen

• Inspection: Contour, hernias.
• Auscultation: Bowel sounds, vascular sounds.
• Palpation: Light and deep, checking for masses.

Lower Extremities

• Inspection & Palpation: Color, swelling, pulses, edema.
• Muscle Strength & Reflex: Babinski test.

Back Assessment

• Inspection: Lesions, skin breakdown.
• Lung Sounds: Auscultate if not done earlier.

Conclusion

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