Head-to-Toe Assessment Nursing | Nursing Physical Health Assessment Exam Skills

Introduction

This tutorial provides a comprehensive guide on performing a head-to-toe nursing assessment. This essential skill is crucial for nursing students and professionals to evaluate a patient's overall health. The assessment follows a systematic approach and includes vital signs, cranial nerve examination, and assessments of various body systems.

Step 1: Prepare for the Assessment

• Perform Hand Hygiene: Always wash your hands before and after patient contact.
• Ensure Privacy: Close curtains or doors to provide a comfortable environment for the patient.
• Introduce Yourself: Explain the procedure to the patient, ensuring they understand and consent to the assessment.

Step 2: Verify Patient Identity

• Check Patient ID: Confirm the patient’s identity by checking armbands.
• Ask Basic Questions: Ensure the patient can state their name, date of birth, and current location.

Step 3: Record Vital Signs

• Measure and Document:
  • Heart rate
  • Blood pressure
  • Temperature
  • Oxygen saturation
  • Respiratory rate
  • Pain level (using a scale of 0-10)

Step 4: Initial Observations

• General Appearance: Note the patient's emotional status, posture, and hygiene.
• Skin Assessment: Look for abnormalities such as lesions, color changes, or signs of distress.

Step 5: Head Assessment

• Inspect Head and Hair:
  • Check for symmetry and involuntary movements.
  • Palpate for masses or skin breakdown.
  • Examine for signs of infestations (e.g., lice).
• Cranial Nerve Assessment:
  • Test facial movements (smile, frown, puff cheeks) for cranial nerve VII function.
  • Palpate the temporal artery and assess the masseter muscle to test cranial nerve V.

Step 6: Eye Assessment

• Inspect Eyes:
  • Check eyelids, sclera, and conjunctiva for abnormalities.
  • Assess pupil size and reaction to light (PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation).
• Cranial Nerve Assessment: Test ocular motor responses (cranial nerves III, IV, VI).

Step 7: Ear Assessment

• Inspect Ears: Look for abnormalities or tenderness.
• Otoscopic Examination: Check the tympanic membrane for color and integrity.
• Cranial Nerve Assessment: Test hearing (cranial nerve VIII) using whispered words.

Step 8: Nose and Mouth Assessment

• Nose Inspection:
  • Check for midline position and patency.
  • Inspect for drainage or abnormalities.
• Mouth Inspection:
  • Assess lips, gums, tongue, and throat.
  • Check for lesions and test cranial nerves IX and X by asking the patient to say "ah."

Step 9: Neck Assessment

• Inspect Neck: Look for symmetry and any lumps.
• Palpate Thyroid and Lymph Nodes: Check for tenderness and size.
• Cranial Nerve Assessment: Test cranial nerve XI by asking the patient to shrug shoulders against resistance.

Step 10: Chest and Lung Assessment

• Inspect Chest: Look for lesions and assess respiratory effort.
• Heart Sounds Auscultation: Use the diaphragm of your stethoscope in five locations:
  • Aortic: Right second intercostal space
  • Pulmonic: Left second intercostal space
  • Erb's Point: Third intercostal space
  • Tricuspid: Fourth intercostal space
  • Mitral: Fifth intercostal space, midclavicular line
• Lung Sounds Auscultation: Assess for normal and abnormal sounds across all lung fields.

Step 11: Abdominal Assessment

• Inspect Abdomen: Check contours and pulsations.
• Auscultate Bowel Sounds: Listen in all four quadrants.
• Percussion and Palpation: Assess for tenderness, masses, or fluid.

Step 12: Extremities Assessment

• Inspect Extremities: Look for skin integrity, lesions, and swelling.
• Palpate Pulses: Check radial, popliteal, posterior tibial, and dorsalis pedis pulses.
• Assess Strength and Mobility: Test muscle strength and range of motion.

Step 13: Back Assessment

• Inspect Back: Check for skin breakdown, lesions, or abnormalities.
• Auscultate Lung Sounds: If needed, listen to lung sounds while the patient is in a prone position.

Conclusion

Performing a head-to-toe assessment is a vital nursing skill that allows for a thorough evaluation of a patient's health. This structured approach helps ensure no aspect of the patient's condition is overlooked. After the assessment, document your findings accurately, and consider reviewing specific areas or skills for further improvement.