1. General Overview
First, you obtain a general overview of the
patient’s health state. These are the details
to keep an eye on in this phase of the
assessment.
-
-
Collect their vital signs. (It’s
encouraged to ask permission
before touching a patient. Also,
explaining what you are doing/what
assessment you are performing will
help the patient feel more relaxed.)
Check heart rate
Measure blood pressure
Take body temperature
Pulse oxymetry
Respiratory rate
Check pain levels
Check hight and weight and
calculate their BMI
2. Hair/ Skin/ Nails
- Once you have a general overview,
you can start from the top of the
body and make your way down. The
assessment is called head to toe for
a reason. Some things to look out for
are:
-
-
Hair distribution(even/uneven)
Hair infestations (lice, alopecia
areata)
Bumps, nits, lesions on the scalp
Tenderness on scalp
Tenderness, lumps on the skin
Lesions, bruising, or rashes on skin
Temperature, moisture, and skin
texture (is the patient pale, clammy,
dry, cold, hot, flushed?)
Edema
Consistency, color, and capillary refill
of nails
Pressure areas
3. Head
- Shape is rounded, symmetrical
- Upon palpation, no nodules, masses
or depressions are identified
- Face appears smooth and
symmetrical with no nodules or
masses present.
4. Eyes
- Check external structures
- Assess eye symmetry
- Check conjunctive and sclera
- Check for PERRLA
- Perform visual acuity test
- Check eyes for drainage
- Check vision with Snellen Chart
- Check six cardinal positions of the
gaze head to toe assessment script
5. Nose
- Palpate nose and check symmetry
- Check septum and inside nostrils
- Patency of nares (patient can breath
through each nostril)
- Check sense of smell
- Palpate sinuses
6. Mouth and Throat
- Check lips for color and moistness
- Inspect teeth and gums
- Examine tongue
- Inspect the inside of mouth
- Look at tonsils and uvula
- Assess hypoglossal nerve by asking
patient to move tongue from left to
right
- Check the patient’s ability to taste, to
swallow, and their gag reflex
7. Ears
- Inspect for drainage or abnormalities
- Test hearing with whisper test
- Look inside ear: inspect the
tympanic membrane and asses ear
discharge
- Tuning fork tests (Weber’s Test,
Rinne Test)
8. Neck
- Check neck muscles to be equal in
size
- Palpate lymph nodes
- Check head movements and
whether they happen with discomfort
- Observe neck range of motion.
- Check trachea placement
- Check shoulder shrug with
resistance
9. Chest: Cardiovascular Assessment
-
-
Listen to the heartbeat. Areas where
to auscultate heart sounds: aortic,
pulmonic, Erb’s point, Tricuspid,
Mitral
Palpate the carotid and auscultate
apical pulse
10. Chest: Respiratory Assessment
- Auscultate lung sounds front and
back
- Observe chest expansion
- Ask abour efforts to
breathe/coughing
- Palpate thorax head to toe
assessment documentation example
11. Abdomen
- Inspect abdomen
- Listen to bowel sounds in all four
quadrants
- Palpate all four quadrants of the
abdomen to check for pain or
tenderness
- Ask about bowel or bladder
problems
12. Extremities
- Assess range of motion and strength
in arms, legs, and ankles
- Assess sharp and dull sensation on
arms and legs
- Inspect arms and legs for pain,
deformity, edema, pressure areas,
bruises
- Palpate radial pulses, pedal pulses
- Check capillary refill on
fingernails/toenails
- Assess gait
- Assess handgrip strength and
equality
13. Back area
Inspect back and spine
Inspect coccyx/buttocks