Nur 120 Fall 2023
STUDENT NAME: ____________________________________
DATE: _______________
Head to Toe Assessment with Vital Signs
Students are expected to state their findings in each Head-to-Toe subsection to the faculty
Students are expected to correct or prompt their partners when needed (Four times allowed)
Vital Sign Assessment (Both students)
Wash hands
S
U
NP
Identify client/Introduce self
S
U
NP
Provide for Privacy
S
U
NP
Explain what you are going to do
S
U
NP
Provide Safety for client (and nurse) before, during, and after procedure
S
U
NP
Temperature: Obtain oral temperature on partner and state result
Pulse: Auscultate apical pulse on the mannequin and state results (must be +/- 2 bpm
from actual rate). Must verbalize landmark to find apical pulse.
S
S
U
U
NP
NP
Respirations: Count mannequin’s respiratory rate and state result (must be +/- 1 RPM
from actual rate).
S
U
NP
Blood Pressure: Correctly obtain systolic and diastolic blood pressure on partner and
state result (must be +/- 4 mmHg from actual SBP and DBP)
S
U
NP
Oxygen Saturation: Apply pulse oximeter to partner’s finger correctly and state result
S
U
NP
S
U
NP
S
U
NP
S
U
NP
S
Chest (assess on mannequin)
 Assess for any chest pain or respiratory problems – SOB (shortness of breath),
cough, difficulty breathing
 Auscultate the mannequin’s lungs, following the correct pattern for auscultation of the
anterior chest (minimum of 7 points), stating rationale for stethoscope placement
Upper Extremities (assess on mannequin)
S
 Palpate radial pulses
 Assess capillary refill
 Assess for strength, movement, and sensation
 Assess skin (esp. in axilla, elbows and in between fingers)
U
NP
U
NP
Head to Toe Assessment (Upper Assessment)
General Survey (assess on mannequin)
 Body position, appearance
 Client’s surroundings (bed, bedrails, table, call bell, personal belongings)
 Visual tubes (oxygen, nasogastric tube, IV, indwelling catheter)
Head (assess on mannequin)
 Assess for symmetry, headache, dizziness, hearing, vision
 Pupil assessment (PERRLA)
 Determine orientation to person, place, time, and situation
 Assess oral cavity (mucous membranes, teeth/dentures, tongue)
 Assess skin behind ears, back of head
Neck (assess on mannequin)
 Ask if the client has any swallowing difficulties
 Palpate carotid pulses, ensuring one side at a time
Nur 120 Fall 2023
Lower Assessment
Abdomen (assess on mannequin)
 Assess for nausea/vomiting, abdominal discomfort/pain, flatus, and last BM
 Inspect the abdomen for shape, presence of drains, dressings
 Auscultate the mannequin’s abdomen for bowel sounds in all 4 quadrants
 Gently palpate the mannequin’s abdomen for areas of firmness and/or tenderness
 Assess skin for any wounds, rashes in abdominal folds
S
U
NP
Genitourinary (assess on mannequin)
 Assess for urinary frequency, pain
 Assess urinary habits (spontaneous? assistive device? last void? amount? color?)
 Assess skin in groin for any rashes, excoriation, lesions
S
U
NP
Extremities (assess on mannequin)
 Assess capillary refill
 Palpate dorsalis pedis pulses
 Assess lower extremity strength, movement, sensation
 Assess skin (especially in between toes and heels).
S
U
NP
Back (assess on mannequin)
 Demonstrate the correct pattern for auscultation of the posterior chest (minimum of 8
points) on mannequin, state rationale for correct positioning of stethoscope
 Assess skin, especially on bony prominences (scapula, vertebrae, sacrum, coccyx),
for presences of wounds, excoriation, rashes, lesions
S
U
NP
Provide Safety for client (and nurse) before, during, and after procedure
 Bed in lowest position
 Bed wheels locked
 Essential items within reach
 Side rails up
 Clean environment
 Perform hand hygiene as leaving the bedside
S
U
NP
Skill Demonstration Result (Faculty to circle):
Satisfactory
Unsatisfactory
If the result is unsatisfactory, both partners must practice for at least one hour before contacting the
nursing lab faculty to make arrangements to repeat the skill demonstration. Practice time and contacting
the faculty must be completed within two weeks of the date of your skill demonstration.
Faculty Signature: _____________________________________________
Student Signature:____________________________________
Comments: