Student Name:
Health Assessment
RNSG 1215
Head to Toe Check-Off
Assess skin color, texture, temp, edema, lesions, body odor, cyanosis, pain during assessment
1. Gather equipment
2. Knock
3. Put on gloves
4. Introduce yourself
5. ID your client (name, birthdate, check armband)
6. Explain the procedure to client
7. Ask/assist client to put on gown
8. Ask the client if they need assistance to empty the bladder
9. Ensure privacy, safety & comfort throughout the assessment
Head & Neck
Assess orientation, behavior, speech
Orientation: person, time, place, & situation
Behavior: Cooperative, happy,
Speech: Clear, Understandable, Appropriate
Inspect & palpate head
Size, shape, hair color and distribution
Lesions, lumps (may indicate trauma), nits
Observe face for symmetry
Facial features, expressions, skin conditions
CN VII – smile, frown, wrinkle forehead, show teeth, puff out cheeks, purse lips, raise eyebrows
CN V & VII – test sensation of forehead, cheeks, chin-soft and sharp
Use two ends of a paper clip-touch forehead, cheeks, & chin
Palpate temporal artery-for elasticity and tenderness
CN V – Palpate temporomandibular joint-for clicking
Test ROM-look to ceiling, chin to chest, chin to shoulder
Palpate lymph nodes-preauricular, postauricular, occipital, tonsillar, submandibular, submental,
Superficial cervical, posterior cervical, supraclavicular-p.282
Observe for enlarged thyroid-non palpable, non-tender
Auscultate & Palpate carotid arteries-less than 10 seconds and one at a time
Assess for jugular vein distension @ 45 °
Eyes
CN II – assess visual function-20 ft. from Snellen or E, glasses are left on
CN III, IV, VI – Inspect external eye-for drainage or lesions
Confrontation-leave glasses on, have 2 ft. away client cover left eye & you cover right, client focus
gaze on you, extend arm, using index finger bring it in until client can see (inferior only, superior,
temporal, & nasal) p.318-peripheral vision,
Corneal light reflex-12in. from face, shine the light over the bridge of nose while the client stares
straight. Reflection of light should be in the same exact spot of each eye
Cardinal fields of gaze-instruct client not to move head, follow the pen through the six cardinal
positions moving in a clockwise direction, eye movement should be smooth and symmetrical
Test PERRLAEyelids-skin, able to close
Eyeballs-sclera
Pass/Fail/Needs Practice (NP)
Test pupil size3-5mm
Ears
Inspect external earsObserve for position and symmetry-top of the ear should align with outer corner of eye
Palpate auricle & mastoid process
Inspect the auricle for lesions, drainage, nodules or redness
Pull the helix back and ask about tenderness (otitis externa)
Behind each auricle noting tenderness, redness, or warmth
Inspect opening of ear canal for drainage, redness, odor, presence of nodules or cysts
CN VIII – Whisper test
2ft behind the client so client cannot see your lips move
Whisper two syllable words “popcorn” or “football”
Nose
Inspect external nose
Shape, patency, color, tenderness
Inspect internal nose
Use otoscope (short, wide tip) or penlight
Use non-dominant hand to gently tilt the client’s head back-inspect septum, nasal mucosadrainage
CN I – Assess smell/identify odors
Have 2 different smells
Palpate sinuses – maxillary & frontal
Press thumbs on maxillary (below the cheek bones) & frontal sinuses-for tenderness/pain
Mouth & Throat
Inspect lips, teeth, gums, buccal mucosa, hard & soft palate
Lips-color, moisture, symmetry, lesions
Teeth-number, color, condition
Gums-color, moisture, lesions
Buccal mucosa-Color, lesions
Hard & soft palate-color and integrity, odor
CN X – Observe uvula – open mouth and say “ah”
Apply tongue depressor-uvula should rise
CN IX & X – Assess for gag reflex
Use a tongue depressor
CN IX & X – have the patient swallow
CN XII – assess tongue strength -put fingers on external cheek and ask client to press with tongue
CN VII & IX – taste-sweet, sour, salt
Musculoskeletal – Upper extremities
CN XI – shoulder shrug & turn head against resistance
Test handgrips
Palpate brachial, ulnar, radial pulses
Test biceps, triceps & brachioradialis reflexes
Test capillary refill
Assess shape of nails
Lungs & Posterior Thorax
Assess posterior thorax
Assess for accessory muscles -trapezius (shoulder)
Auscultate posterior chest – 10 places-p.396
Observe spinal curvature
Lungs & Anterior Thorax
Inspect anterior thorax
Have client sit with arms at sides-stand in front and assess for shape and configuration
Assess for accessory muscles
Sternomastoid and rectus abdominus
Assess rate, rhythm & pattern of respirations
Assess breath sounds – 10 places (p. 601)
Assess chest configuration
Normal chest shape, with no visible deformities, such as a barrel chest, kyphosis, or scoliosis. No muscle
retractions when breathing
Test skin mobility, turgor
Assess apical heart rate
Heart
Auscultate aortic, pulmonic, Erb’s point, tricuspid mitral valves (p.441)
Auscultate apical pulse
Abdomen
Inspect abdomen
Skin, contour, symmetry-aortic pulsations
Auscultate bowel sounds
Use diaphragm of stethoscope
Begin RLQ and go clockwise
Palpate abdomen
Tenderness, resistance, guarding
Masses
Musculoskeletal – Lower extremities
Assess hair distribution
Assess for edema
Assess popliteal, dorsalis pedis & posterior tibial pulses
Perform pedal push & dorsal flexion against resistance
Assess shape of nails
Assess capillary refill
Test patellar, Achilles, plantar reflexes
Romberg
Ask client to stand erect with arms at side and feet together
Note unsteadiness or swaying
Then with the client in the same position, ask the client to close eyes for 20 sec.
Again note imbalance or swaying
Gait
Note weight bearing stability
Foot position
Posture
End of Assessment
Thank the client
Make sure everything is within reach for the client
Make sure one side rail is down
Ask if there is anything else you can do for them before you leave
Signatures
Faculty Signature:
Student Printed Name:
Date:
G#
Student Signature:
Final Check-Off
Pass
Fail