HEAD TO TOE CHECKOFF:
Patient record & Verify Dr. Orders
Assess for procedure need
PERSONAL PROTECTIVE EQUIPMENT (gloves)
Disposal of waste
Knock, knock
“Good afternoon. My name is ____________. I will be your student nurse for today. I will be doing a full
head to toe exam. Is that ok?”
“Great, I will wash my hands, gather my supplies and I will be right back.”
tongue blade
coffee beans
tuning fork
stethoscope
penlight
reflex hammer
Cotton ball
Eye Cover
Otoscope
Rosenbaum Chart
Tape measure
gloves
ASSESS FOR ALLERGIES
“Are you allergic to latex?”
“Do you have any allergies?”
HAND HYGIENE
PROVIDE PRIVACY
ASSESS FOR SAFETY
Closes curtain
PATIENT IDENTIFICATION
“Can you confirm your first and last name?”
“Can you confirm your date of birth?”
ASSESS ORIENTATION
“Do you know where you are right now?”
“Do you know what today’s date is? How about the year?”
Assess level of consciousness
“do you know why you’re here?”
“Patient is conscious, alert and oriented x4”
VERBALIZE “Patient’s height, weight, BMI, and vital signs including temperature, pulse, respiration,
and blood pressure all within normal ranges and already in the chart”
Note general appearance
“height & weight are in portion to stature, body movements are voluntary, coordinated, smooth &
even”
Observe posture and positions
“posture is erect, & position is relaxed”
Note facial expression, mood /affect
“pt. mood, affect, & facial expression appropriate for situation”
Note hygiene, grooming, and dress
“patient is clean, well-groomed, appropriate attire for season with no odors”
Note mobility aids, medical equipment, dressings, and ostomies
“Do you use mobility aids at home? No noted medical equipment, dressings, or ostomies”
ASSESS FOR PAIN
“Are you feeling any pain right now?”
Test immediate, recent, and remote memory
“I am going to say four words. I want you to repeat after me and remember them. In a few minutes I will
ask you recall them: green, purple, money, and love”
SKIN
Inspect skin for color, hair distribution, lesions and wounds
Inspect and palpate skin on arms, palpate down legs to inspect for edema, look at skin on legs
Place back of hand on patient’s hand to check for temperature. Turn hand to posterior and inspect.
“patient’s skin is uniform in color, unblemished, with no lesions, wounds or infestations. No edema
noted. Even hair distribution on legs.”
“Patient’s skin is smooth, moist and warm to touch
PINCH SKIN FOLD OVER CLAVICLE TO CHECK SKIN TURGOR
“normal skin turgor, and elasticity”
Check for blanching on any reddened areas
“no visible blanching”
CHECK CAPILLARY REFILL
“Capillary refill less than 3 seconds. No signs of clubbing in fingernails.”
HEAD, FACE, NECK
Inspect head for size and shape, placement of features and hair distribution
“head size and shape is normocephalic, and face is symmetrical ”
Sanitize hands
Put on gloves
Palpate skull and hair
“there are no signs of infestation observed. Hair is thick, shiny, & evenly distributed”
CN 5 - TRIGEMINAL
ASK CLIENT TO BITE DOWN
ASK CLIENT TO CLOSE HIS EYES AND REPORT LIGHT/SHARP TOUCH
(3 places both sides of face, ophthalmic, maxillary, mandibular)
“TRIGEMINAL NERVE INTACT”
CN 7 –FACIAL
ASK CLIENT TO SMILE, FROWN, SHOW TEETH, RAISE EYEBROWS, PUFF CHEEKS
“FACIAL NERVE INTACT”
Examine neck
Check for thyroid enlargement
“thyroid does not appear to be enlarged”
“Can you move your neck for me, so we can check range of motion?”
PALPATE LYMPH NODES
PRE AURICULAR (in front of ear)
POST AURICULAR (behind ear)
OCCIPITAL (behind head)
ANTERIOR CERVICAL (top front of cervical)
POSTERIOR CERVICAL (bottom back of cervical)
TONSILLAR (below ear)
SUB-MANDIBULAR (lower chin, top of neck)
SUB-MENTAL (under chin)
SUPRA-CLAVICULAR (above clavicle)
INFRA-CLAVICULAR (below clavicle)
AXILLARY (armpit) VERBALIZE AND POINT
INGUINAL (groin) VERBALIZE AND POINT
“No swollen lymph nodes noted”
CN 11 – SPINAL ACCESSORY
“ASK CLIENT TO TURN HEAD TO EACH SIDE AGAINST RESISTANCE”
PRESS HAND AGAINST CHEEK AND SHRUG SHOULDERS AGAINST RESISTANCE
EYES
“eyebrow & eyelashes are evenly distributed”
“sclera appears white, with no inflammation of bulbar conjunctivae. Iris intact”
Retract lower lids to note palpebral conjunctivae
“palpebral conjunctivae are pink, shiny, smooth”
“No drooping of the upper lids or sagging of the lower lids”
CN 3 – OCCULOMOTOR
ASK PT. TO OPEN/CLOSE EYES, & RAISE EYELIDS
SHINE LIGHT ONTO EACH PUPIL TO TEST FOR PERRLA
“We are going to shine a light into each pupil to check for constriction. Look straight. Pupils Equal
Round and Reactive to Light and Accommodation. Pupil size 3”
CN 3, 4, 6 – OCULOMOTOR, TROCLEAR, ABDUCENS
CHECK EXTRAOCULAR MOVEMENT /SIX CARDINAL FIELDS OF GAZE
“Follow the penlight with your eyes.”
CN 2 – OPTIC
TEST VISUAL ACUITY
SNELLEN - (20 ft away)
ROSENBLUM- (14 inches away)
“PLEASE READ THE FOLLOWING LINE” “PT. HAS 20/20 VISION”
“I would do the same for the other eye”
“No eye muscle weakness noted”
“Test recent memory: do you remember the four words I told you earlier can you repeat them again”
EARS, NOSE, THROAT
“Ears are symmetrical with no visual discharge”
Palpate pinna and tragus
“No tenderness of the pinna or tragus”
CN VIII – ACOUSTIC (Vestibulocochlear)
TEST HEARING WITH WHISPER, RINNE, & WEBER
Close one ear, whisper, have patient repeat
Close other ear, whisper, have patient repeat
Weber test on top
Rinne test—hold against bone on back of ear, tell patient to let me know when they no longer hear it,
and move to front of ear.
“I would do this to both ears. Air conduction is two times longer than bone conduction. Sound heard
equally in both ears”
INSPECT INNER EAR WITH OTOSCOPE, ASSESS TYMPANIC MEMBRANE.
“tympanic membrane is pearly grey, no signs of wax”
“nose is aligned, with no discharge”
Use penlight up nose
“septum is midline”
“nares are patent with pink nasal mucosa”
Palpate frontal and maxillary sinuses
“no tenderness notes on frontal or maxillary sinuses”
CN 1– OLFACTORY
ASK PATIENT TO IDENTIFY FAMILIAR SMELLS
“OLFACTORY NERVE INTACT”
“close one nostril and sniff, close the other and sniff”
CN 9 and 10– GLOSSOPHARYNGEAL AND VAGUS
CHECK GAG REFLEX (verbalize)
ASK PT TO SWALLOW
“GLOSSOPHARYNGEAL & VAGUS NERVE INTACT”
CN 12- HYPOGLOSSAL
“STICK OUT YOUR TONGUE AND MOVE IT RIGHT AND THEN LEFT”
“HYPOGLOASSAL NERVE INTACT”
“lips are pink and moist,
open mouth,
oral mucosa, gums, teeth, tongue, and uvula all intact”
RESPIRATORY:
Ask about trauma, surgery, and other conditions that affect respiration
“have you had any previous trauma, surgery or other conditions that would affect respiration?”
“patient is not on any oxygen”
“thorax is symmetric with no deformities”
“no labored breathing”
INSPECT, PALPATE AND PERCUSS OVER ANTERIOR AND POSTERIOR CHEST
PALPATE POSTERIOR CHEST
PERCUSS SIDE TO SIDE
Check lung expansion with hands on back, breathe in, breathe out
“lung expansion symmetrical”
Check for tactile fremitus
“I am going to have you say the number 99 for me three times”
Diaphragmatic Excursion:
“breathe in and out. Hold”
Percuss down from apices to rib 6, mark
“deep breath in and hold”
Percuss down from rib 6 to 10 and measure
“Diaphragmatic excursion is 4 cm, within the normal 3-5 cm range”
USE DIAPHRAGM OF STETHOSCOPE TO AUSCULTATE OVER ALL LUNG FIELDS
ASCULTATE SIDE TO SIDE
“Lungs clear and equally bilateral”
OBSERVE FOR JUGULOVENOUS PULSATION AND DISTENTION (JVD) (PATIENT SHOULD BE LYING
IN BED WITH HEAD 30-45 DEGREE)
“turn your head to the side, turn your head this side”
“JUGULAR VEIN NOT DISTENDED, PATIENT SHOULD BE LYING IN BED WITH HEAD 30-45 DEGREES”
CAROTID PULSE: LISTEN FOR BRUIT USING BELL OF STETHOSCOPE BEFORE PALPATES (ONLY
ON ONE SIDE AT A TIME)
“no bruits noted”
AUSCULTATE OVER FIVE CARDIAC LANDMARKS WITH BELL & DIAPHRAGM
AORTIC (right 2nd intercoastal space)
PULMONIC (left 2nd intercoastal space)
ERBS (left 3rd intercoastal space)
TRICUSPID (4th intercoastal space, left sternal border)
MITRAL (5th intercoastal space, midclavicular)
“ALSO WHERE WE MEASURE THE APICAL PULSE AND PMI”
“I WOULD COUNT FOR 60 SECONDS”
“rate is within normal range, rhythm is regular and quality is strong”
“S1 heart sound is when the AV valves close at the apex”
“S2 heart sound is when the semi-lunar valves close at the base”
ASSESSES PERIPHERAL PULSES:
COMPARES BILATERALLY
1.
2.
3.
4.
5.
6.
7.
8.
TEMPORAL
CAROTID
BRACHIAL
RADIAL
FEMORAL
POPLITEAL
POSTERIOR TIBIAL
DORSALIS PEDIS
“PULSES ARE BILATERIALLY REGULAR, & STRONG”
ABDOMEN
FOLLOW SEQUENCE OF INSPECTION, AUSCULTATION, PERCUSSION, PALPATION
Observe contour from two angles
“abdomen appears flat, symmetrical, with no lesions, scars or hair”
“no inguinal or umbilical hernias noted”
AUSCULTATE BOWEL SOUNDS IN FOUR QUADRANTS (starts at ileocecal valve-RLQ, listen to each
quadrant for 1 minute)
“ACTIVE BOWELS SOUND IN ALL FOUR QUADRANTS”
“I would listen for 3 to 5 minutes in each quadrant, if abnormal I would listen for 5 minutes.”
Using bell of stethoscope, auscultate abdominal aorta for bruit
“no noted bruits of the abdominal aorta”
Percuss four abdominal quadrants
PERCUSS AND MEASURE LIVER SPAN
PERCUSS STARTING AT T2, DOWN TO T5 WHEN YOU HEAR DULLNES, MARK
START AT SPACE 12 AND PERCUSS UP TO 10 (WHEN YOU HEAR DULLNESS), MARK AND MEASURE
LIVER SPAN
LIVER SPAN SHOULD BE SPACE 5 TO 10, ABOUT 7 CM
“LIVER SPAN 7 CM, WITHIN NORMAL RANGE”
Palpate four abdominal quadrants
“ARE YOU FEELING ANY ABDOMINAL PAIN?”
“no lumps, masses, or tenderness”
Check for rebound tenderness in right lower quadrant (for appendix)
“no rebound tenderness observed”
VERBALIZES TO CHECK FOR COSTOVERTEBRAL-ANGLE(CVA) TENDERNESS OF THE KIDNEYS
BY THE 12TH RIB ON THE BACK. PLACE HAND AND POUND WITH FIST
“NO PAIN OR TENDERNESS NOTED”
MUSCULOSKELETAL
Inspect overall appearance of musculoskeletal
“muscles equal on size both sides of the body, smooth coordinated movement”
OBSERVE SPINE FROM LATERAL AND POSTERIOR VIEWS FOR NORMAL CURVATURE
“BEND AND TOUCH YOUR TOES”
“spine is vertically aligned”
Palpate along spine
“no sign of scoliosis”
“I am going to test muscles strength of all limbs.”
Push palms up against resistance
Push hands out against resistance
“Muscle strength is 5 on a scale from 0 to 5. I would do these for the legs also.”
Test range of motion of all limbs
Arms
“to move arm away from body, then towards the body” “to bend arm, then extend”
“to rotate arm in a circle”
“I would perform these on the lower limbs as well”
Palpate skin, joints, and muscle groups of upper and lower extremities
“no lumps, masses, or tenderness”
NEUROLOGICAL
“do you remember the four words I told you earlier can you repeat them again”
“to test for remote memory I would ask what you did before starting the program?”
Perform Romberg’s test for balance
“Close your eyes with you arms out”
“Walk in a straight line, heel to toe to test your balance and motor function”
TEST DEEP TENDON REFLEXES
BICEPS (C5&C6)- SUPPORT PT. FOREARM, PLACE THUMB ON BICEP TENDON, HIT HAMMER TO
THUMB
TRICEPS (C7 &C8)-WHILE SUSPENDING UPPER ARM
“TELL PT. TO JUST GO LIMP” STRIKE TRICEP TENDON WITH HAMMER
PATELLAR- ASK PT. TO DANGLE LEGS” HOLDING ABOVE KNEE, STRIKE TENDON
ACHILLES- HOLDING TOES, DORIFLEX FOOT, TAP TENDON WITH HAMMER
“2+ NORMAL REFLEXES”
“I would document according to facility policy and verbalizes any abnormalities, which there were
none”
Wash hands