Head 2 Toe Assessment

Question 1

Start with head and go in order till you get upper body

Answer 1

1. Introduce
2. Explain
3. Ask pt name/dob/location/event
4. Inspect scalp
   5.use penlight to assess PERRLA and cardinal gaze
5. Penlight to check ears
6. Penlight to check nose
7. Penlight to check mouth
8. Smile and show teeth
9. Tongue out/ side to side/roof of mouth
10. Eyebrow rise/wrinkle forehead
11. inspect and palpate neck
    13.carotid pulse
12. Shoulder shrug
13. Turgor

Question 2

Start with Upper extremity and end before lower extremity.

Answer 2

1. Heart sounds (4) clean stethoscope
2. Anterior lung sounds (7)
3. Inspect abdomen
   -look
   -listen
   -feel
   -ask about bowel and urination.
4. Posterior lung sounds (10)
5. Inspect back
6. Inspect BUE
7. BUE up down and out
8. Bring together and wrist circles
   9.wrist flex ion and extension
9. Finger grasp
10. Radial pulse
11. Capillary refill
12. Clubbing

Question 3

Start at lower extremity and finish with perineal

Answer 3

1. Inspect BLE
2. Check pedal pulses
3. Toe wiggle
4. Toe push
5. Toe up
6. Cap refill
   7.Ankle circles
7. ROM knee up and out
8. Perineal exam