Head to Toe Assessment

Question 1

introduction

Answer 1

• name
• role
• 2 patient identifiers
• process & procedures
• comfort & privacy
• allergies

put bed up to working height

Question 2

LOUDCARTS

Answer 2

location
onset
duration: waning, comes and goes
characteristics: dull, achy, throbbing
accompanying symptoms
relief methods: sitting down
treatments meds: tylenol
severity of pain
understanding

Question 3

LOC

Answer 3

patient alert & awake

Question 4

Orientation

Answer 4

can you state your name one more time?
do you know what building we’re in?
do you know today’s date?

patient alert to person, place, and time

Question 5

facial expression/symmetry

Answer 5

Can you raise your eyebrows, puff out your cheeks, and give me a smile?

patient no drooping of mouth

patient palpebral fissure and nasolabial folds are symmetrical

no periorbital edema

cranial nerve 7 facial nerve is intact

Question 6

Pupils

Answer 6

Penlight: from outer corners to inwards.

Follow the tip of my pen with your eyes, not moving your head.

pupils are equal, round, and reactive to light and accommodation

cranial nerve 3, oculomotor nerve is intact

can you look straight ahead at that object
shine light from 2 ft away midline

Corneal light reflex intact

Question 7

Lips

Answer 7

can you pull your lips down so I can check the inside of your lips?

penlight

color even and moist

Question 8

Tongue

Answer 8

can you open your mouth wide and stick out your tongue?

penlight

color even and moist

can you say light, tight, dynamite?

cranial nerve 12 hypoglossal nerve intact

Question 9

neck

Answer 9

** Inspect & palpate tracheal position**

midline

I’m going to take your pillow so I can look at your neck. Can you look left for me?

penlight

no JVD

can you cough for me?
cough reflex intact

Question 10

skin

Answer 10

can you lift your arms up for me?
penlight
skin color consistent with genetic background, and intact

use dorsal side of hands to feel arms
skin warm and dry

Question 11

hands

Answer 11

palpate both radial pulses at the same time
radial pulses 2+ bilaterally

can you grip my hands tight
grip strength equal bilaterally

Does your ring feel tight?
No edema in the hands.

Question 12

nails

Answer 12

cap refill
Less than 2 seconds

inspect nails
color even, no ridging, no clubbing

Question 13

chest

Answer 13

inspect symmetry 360*
chest symmetrical

respirations unlabored and regular
no accessory muscle use, nasal flaring, or intercostal retractions.

AP diameter is 1 to 2

Question 14

ant Lungs

Answer 14

lungs cleat to auscultation anteriorly

Question 15

post lungs

Answer 15

lungs clear to auscultation posteriorly

chest expansion
chest expansion symmetrical

Question 16

heart

Answer 16

Aortic, 2nd ICS, RSB, S2>S1
Pulmonic, 2nd ICS, LSB, S2>S1
Erbs, 3rd ICS, LSB, S1=S2
Tricuspid 4th ICS, LSB, S1>S2
Mitral 5th ICS, MCL, S1>S2

go back with bell
no extra hearts sounds or murmurs

Question 17

abdomen inspection

Answer 17

Abdomen flat and symmetrical
no masses
aortic pulsations visualized in left epigastric area
umbilicus midline and inverted

Question 18

ab ausc

Answer 18

bowel sounds heard in all 4 quadrants

Question 19

ab palpate

Answer 19

abdomen soft and nontender

Question 20

GI questions: stools

Answer 20

When was last BM?
What color was it?
Was it soft/hard?
How often do you go?
Was it a normal amount for you?

Question 21

urine questions

Answer 21

When did you last urinate?
What was the color?
Was it a normal amount for you? Any odor?

Question 22

inspect legs

Answer 22

legs symmetrical
no lesions or scars

hair consistent with age, gender, and ethnicity

skin color consistent with genetic background and intact

color is even with no ridging or thickening

Question 23

palpate legs

Answer 23

**dorsal hands*
warm and dry

*press shin, ankle, feet 5 seconds**
no pitting edema

press toes
less than 2 seconds

Question 24

palpate lower extremity pulses

Answer 24

dorsalis pedis 2+ bilaterally
posterior tibial 2+ bilaterally

Question 25

plantar flexion
dorsa flexion

Answer 25

push against my hands

point your toes towards you against my hands

equal bilaterally

Question 26

closing

Answer 26

Okay. Exam is finished.
If you need anything just let me know.
I will be back to check on you.
Here’s your call light
Let me lower your bed

Question 27

Ab percussion

Answer 27

Typany heard in all 4 quadrants