Head To Toe Assessment NUR 201 Fall 2018 Jensen

Head to Toe Assessment NUR 201 Fall 2018 Jensen
First – introduce yourself and role, the exam process. Observe general appearance, position in bed, skin color, breathing,
name band, lighting, call bell, equipment, fall risk.
Second – remember – you need to focus your assessment to your patient and talk with him or her. Wash hands and glove
as appropriate; only uncover what you are examining (remember privacy, warmth).
Not Comments
done
HEENT: 2: Performed
 Assess mental status (LOC, A & O x3, follow simple commands) correctly
 Inspect for hearing and vision (read newsprint, functional hearing, any assistive 1: Needs more
devices?) practice
 Inspect skin, head, facial movements, PERRLA . lights on. 0: skill not
 Inspect conjunctiva, sclera performed
 Inspect oropharynx (condition, uvula rises)
Neck:
 Inspect skin, trachea, neck vein distention (JVD), carotid pulses (feel for thrill),
ROM, strength
Upper extremities:
 Inspect arms, hands, skin, nails, joints.
 Circulation bilateral compare symmetry (color, temp, cap refill, radial pulses),
Movement (strength /grasp, ROM), Sensation (to touch, paresthesia).
Anterior chest:
 Inspect chest wall diameter, movement
 Auscultate breath sounds – compare sides; note normal, abnormal or
adventitious sounds
 Auscultate heart sounds –Erb point, for rate, rhythm, S1 S2, extra sounds,
murmurs. One minute.
 Note any shortness of breath, sputum, cough
Abdomen:
 Inspect abdomen shape, color, scars, movement
 Auscultate bowel sounds all four quads. Percuss abdomen all 4 quadrants.
 Lightly palpate for tenderness, masses all 4 quadrants. Deep if indicated.
 Assess appetite. Last BM? Last voiding?
Lower extremities:
 Inspect skin, legs,joints, feet, between toes, nails. Assess edema
 Circulation symmetrical (color, temp, cap refill, dorsalis pedis pulses),
Movement (strength /resistance, ROM) Sensation (to touch, paresthesia)
Posterior chest, back:
 Inspect breathing, shape, skin
 Auscultate breath sounds and apex to bases, 10 locations
 Inspect lower back (skin, alignment, redness, edema)
 Inspect spine, sacrum, pressure points if immobile
Standing:
 Balance, transfer, gait, coordination
Closure
Summarize findings for patient. Does this sound accurate? Do you have any concerns?
Assess room for safety (bedside table, lights, call light, toileting) . Share initial plan of care.
Is there anything else I can do? Close interview.
Head to Toe Assessment
NUR 201 Fall 2018 Jensen
Student Last Name , First (Print) ________________________________________________ Week of Nov 26 2018
Assessments Met 2 Improvements Communication,

-Not Met organization,
1-0 confidence,
accuracy
1.Introduce self to client using therapeutic communication, proper
hand hygiene, Identify client by name band & name with two
identifiers.
2. HEENT, Neck
3. Upper extremities
4. Anterior chest lungs, heart
5. Abdomen
6. Lower extremities.
7. Posterior chest, lungs, spine
8 . Standing, gait
9. Confident, efficient, organized, accurate, clear communication.

Talks to patient, privacy and draping. Provides comfort.
10. Disposes of equipment and washes hands, plan, closure. Safety

check. Completed within 15-20 minutes.
FINAL SCORE TOTAL 20 POINTS

(19=95%, 18=90%, 17=85%, 16=80%, 15=75%, 14=7-%, 13=65%,
12=60%, 11=55%, 10=50%)
FINAL PERCENTAGE________________
Comments
Instructor_______________________________Date________________
Head to Toe Assessment NUR 201 Fall 2018 Jensen
First – introduce yourself and role, the exam process. Observe general appearance, position in bed, skin color, breathing,
name band, lighting, call bell, equipment, fall risk.
Second – remember – you need to focus your assessment to your patient and talk with him or her. Wash hands and glove
as appropriate; only uncover what you are examining (remember privacy, warmth).
Gather equipment, prepare yourself
HEENT:
 Assess mental status (LOC, A & O x3, follow simple commands)
 Inspect for hearing and vision (read newsprint, functional hearing, any assistive devices?)
 Inspect skin, head, facial movements, PERRLA . lights on.
 Inspect conjunctiva, sclera
 Inspect oropharynx (condition, uvula rises)
Neck:
 Inspect skin, trachea, neck vein distention (JVD), carotid pulses (feel for thrill), ROM, strength
Upper extremities:
 Inspect arms, hands, skin, nails, joints.
 Circulation bilateral compare symmetry (color, temp, cap refill, radial pulses), Movement (strength
/grasp, ROM), Sensation (to touch, paresthesia).
Anterior chest:
 Inspect chest wall diameter, movement
 Auscultate breath sounds – compare sides; note normal, abnormal or adventitious sounds
 Auscultate heart sounds –Erb point, for rate, rhythm, S1 S2, extra sounds, murmurs. One minute.
 Note any shortness of breath, sputum, cough

Abdomen:
 Inspect abdomen shape, color, scars, movement
 Auscultate bowel sounds all four quads. Percuss abdomen all 4 quadrants.
 Lightly palpate for tenderness, masses all 4 quadrants. Deep if indicated.
 Assess appetite. Last BM? Last voiding?
Lower extremities:
 Inspect skin, legs,joints, feet, between toes, nails. Assess edema
 Circulation symmetrical (color, temp, cap refill, dorsalis pedis pulses), Movement (strength
/resistance, ROM) Sensation (to touch, paresthesia)
Posterior chest, back:
 Inspect breathing, shape, skin
 Auscultate breath sounds and apex to bases, 10 locations
 Inspect lower back (skin, alignment, redness, edema)
 Inspect spine, sacrum, pressure points if immobile
Standing:
 Balance, transfer, gait, coordination
Closure
Summarize findings for patient. Does this sound accurate? Do you have any concerns?
Assess room for safety (bedside table, lights, call light, toileting) . Share initial plan of care.
Is there anything else I can do? Close interview.

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Head to Toe Assessment NUR 201 Fall 2018 Jensen

Student Last Name , First (Print) ________________________________________________ Week of Nov 26 2018

Assessments Met 2 Improvements Communication,

4. Anterior chest lungs, heart

7. Posterior chest, lungs, spine

9. Confident, efficient, organized, accurate, clear communication.

10. Disposes of equipment and washes hands, plan, closure. Safety

FINAL SCORE TOTAL 20 POINTS

name band, lighting, call bell, equipment, fall risk.

Gather equipment, prepare yourself

 Assess mental status (LOC, A & O x3, follow simple commands)

 Inspect skin, head, facial movements, PERRLA . lights on.

 Inspect conjunctiva, sclera

 Inspect oropharynx (condition, uvula rises)

 Inspect arms, hands, skin, nails, joints.

/grasp, ROM), Sensation (to touch, paresthesia).

 Inspect chest wall diameter, movement

 Note any shortness of breath, sputum, cough

 Inspect abdomen shape, color, scars, movement

 Lightly palpate for tenderness, masses all 4 quadrants. Deep if indicated.

 Assess appetite. Last BM? Last voiding?

 Inspect skin, legs,joints, feet, between toes, nails. Assess edema

/resistance, ROM) Sensation (to touch, paresthesia)

Posterior chest, back:

 Inspect breathing, shape, skin

 Auscultate breath sounds and apex to bases, 10 locations

 Inspect lower back (skin, alignment, redness, edema)

 Inspect spine, sacrum, pressure points if immobile

 Balance, transfer, gait, coordination

Is there anything else I can do? Close interview.

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