Chapter 22
Conducting a
Head-to-Toe Examination
Kevin Dobi MS, APRN
Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Conducting a
Head-to-Toe Assessment
• Although you began with knowledge and techniques
specific for each system, patient comes to you as a
whole person.
• You must organize your techniques to examine entire
person, literally from “head to toe.”
• Begin with head, examine facial characteristics, skin, hair,
eyes, ears, mouth, throat, and range of motion of neck in a
systematic, organized manner, incorporating neurologic,
integumentary, musculoskeletal, visual, and auditory
systems within head, neck, nose, and mouth regions.
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Conducting a Head-to-Toe
Assessment (contd.)
• Then you must move on to next region of body and
repeat same:
• After all body regions examined, document your findings
by body system.
• Each nurse’s approach to a head-to-toe assessment is
unique.
• No two nurses do things in exactly same manner, nor are
any two patients exactly the same.
• As a student, you determine what examination sequence
works best for you.
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Conducting a Head-to-Toe
Assessment (contd.)
• It is important to develop a systematic method so
that you do not omit any data.
• When performing a focused assessment, refer only to
those regions needed based on patient’s chief
complaint and additional data learned from history.
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Performing a
Health Assessment
• Assessment begins with general survey when first
meeting patient:
• Observe patient enter room, and note gait, posture, and
ease of movement.
• Shake hands; note eye contact and firmness of hand grip.
• Introduce self; data collection begins by asking patient
reason for seeking care.
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Performing a
Health Assessment (contd.)
• Note language spoken and gross hearing and speech
capability.
• Observe for obvious vision difficulties or blindness
and any difficulty standing, sitting, or rising.
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Performing a
Health Assessment (contd.)
• Observe musculoskeletal difficulties:
• General affect, interest, and involvement.
• Dress and posture.
• General mental alertness, orientation, and integration of
thought processes.
• Obvious shortness of breath or posture that facilitates
breathing.
• Obesity, emaciation, or malnourishment.
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Performing a
Health Assessment (contd.)
• After initial observations, obtain history, assess vital
signs and vision, and prep for examination.
• Instruct patient to empty bladder, and collect
specimen, if necessary.
• Have patient remove clothing, put on gown, and sit
on examination table.
• Conduct a focused assessment that accommodates
patient’s needs.
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Performing a
Health Assessment (contd.)
• Use following sequence only as guide.
• Developed to demonstrate how one body system
examination is integrated with other body systems to
permit a comprehensive regional assessment.
• Most important:
• Be organized.
• Develop a routine; it helps with consistency. SCRIPT
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Performing a
Health Assessment (contd.)
• Before beginning assessment, have clear picture in
mind of what you plan to do and in what order.
• Practice, practice, practice; learn to become
systematic and inclusive.
• Imagine yourself as patient, and consider how you
would want nurse to be prepared to assess you.
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Guidelines for Adult
Head-To-Toe Examination
• Assessment data collected in general survey during
history includes:
• Level of consciousness and mental status.
• Mood or affect.
• Personal hygiene.
• Skin color.
• Posture and position.
• Mobility.
• Ability to hear and speak.
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Guidelines: Assess Vital Signs and
Other Baseline Measurements
• Temperature, radial pulse, respirations, and blood
pressure (both arms if indicated).
• Height, weight, and body mass index.
• Visual acuity.
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Guidelines:
Examine Hands
• When taking pulse and blood pressure, inspect skin
surface characteristics, temperature, and moisture of
hands.
• Inspect for symmetry.
• Inspect/palpate nails for shape, contour, consistency,
color, thickness, cleanliness, and clubbing.
• Test capillary refill.
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Guidelines:
Examine Head and Face
•
•
•
•
•
Inspect skull for contour; hair for color and distribution.
If indicated, palpate hair for texture; palpate scalp.
Palpate temporal pulses.
Inspect for facial features and symmetry.
Inspect bony structures of face for size, symmetry, and
intactness.
• If indicated, ask patient to clench teeth and clench eyes
tight, wrinkle forehead, smile, stick out tongue, and puff
out cheeks.
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Guidelines:
Examine Head and Face (contd.)
• Inspect bony structures of face for size, symmetry,
and intactness.
• Evaluate sensitivity of forehead, cheeks, and chin to light
touch.
• Complete an assessment of cranial nerves.
• Inspect skin for color and lesions.
• If indicated, palpate skin surfaces, facial bones, and
sinus regions; and transilluminate sinuses.
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Guidelines:
Examine Head and Face (contd.)
• Eyes:
• Near and peripheral vision.
• Inspect eyebrows for hair distribution, underlying skin, and
symmetry.
• Inspect eyelids and eyelashes for symmetry, position,
closure, blinking, and color.
• Inspect conjunctiva and sclera for color and clarity; inspect
cornea for transparency.
• If indicated, inspect anterior chamber.
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Guidelines:
Examine Head and Face (contd.)
• Eyes:
• Inspect symmetry of eye movement.
• Test extraocular eye movement.
• Perform cover-uncover test .
• Inspect iris for shape and color.
• Assess pupil: Direct and consensual reaction, corneal light
reflex, accommodation.
• Ophthalmic examination: Inspect red reflex, disc cup
margins, vessels, retinal surface, and macula.
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Guidelines:
Examine Head and Face (contd.)
• Ears:
• Inspect external ear and auditory canal.
• Alignment, position, size, shape, symmetry, skin
color, intactness.
• Discharge or lesions.
• Palpate external ear and mastoid areas for tenderness, edema,
or nodules.
• If indicated, perform whisper test to evaluate
gross hearing.
• Perform Rinne’s and Weber’s tests.
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Guidelines:
Examine Head and Face (contd.)
• Ears:
• Otoscopic examination: Inspect characteristics of external
canal, cerumen, and eardrum (landmarks)
• Palpate lymph nodes of head.
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Guidelines: Examine Nose, Mouth,
and Oropharynx
• Assess nasal structure and septum.
• Assess nose for patency, symmetry, and discharge.
• If indicated, evaluate sense of smell.
• Lips, buccal mucosa, and gums for color, symmetry,
moisture, and texture.
• Assess teeth for number, color, position, alignment,
hygiene, and condition.
• Assess floor of mouth and hard and soft palates for
color and surface characteristics.
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Guidelines: Examine Nose, Mouth,
and Oropharynx (contd.)
• Assess oropharynx for odor, anterior and posterior
pillars, uvula, tonsils, and posterior pharynx
• If indicated, grade tonsils.
• Assess tongue for symmetry, movement, color, and
surface characteristics.
• If indicated, palpate tongue and gums, evaluate gag reflex,
and test temporomandibular joint for movement.
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Guidelines:
Examine Neck
• Observe symmetry and smoothness of neck, trachea,
and thyroid.
• If indicated, palpate trachea and thyroid.
• Inspect neck for range of motion.
• If indicated, test range of motion of head and neck; have
patient shrug shoulders against resistance.
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Guidelines:
Examine Neck (contd.)
• Palpate carotid pulses (one at a time).
• If indicated, auscultate for bruits.
• Palpate lymph nodes of the neck.
• Observe for jugular venous distention.
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Guidelines:
Examine Upper Extremities
• Inspect patient’s arms for skin characteristics,
symmetry, and deformities.
• Palpate:
• Arms, elbows, and wrists for temperature, tenderness, and
deformities.
• Brachial or radial pulse for presence and amplitude.
• If indicated, epitrochlear lymph nodes.
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Guidelines:
Examine Upper Extremities (contd.)
• If indicated:
• Test range of motion, muscle strength, and sensation.
• Test and bilaterally compare deep tendon reflexes.
• Perform Phalen’s sign or Tinel’s sign to assess for carpal
tunnel syndrome.
• Test for rotator cuff damage.
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Guidelines:
Assess Posterior Chest
• Nurse moves behind patient; patient is seated—gown
to waist for men; gown opened in back for women.
• Observe posterior and lateral chest for symmetry of
shoulders, muscular development, scapular placement,
spine alignment, and posture.
• Inspect skin for color, intactness, lesions, and scars.
• Palpate vertebrae for alignment and tenderness.
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Guidelines:
Assess Posterior Chest (contd.)
• Observe respiratory movement for excursion,
symmetry, depth, and rhythm of respirations.
• If indicated, palpate:
• Posterior chest and thoracic muscles for tenderness, bulges,
and symmetry.
• Chest wall for thoracic expansion; posterior chest wall for
fremitus.
• Down vertebral column for alignment and tenderness.
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Guidelines:
Assess Posterior Chest (contd.)
• If indicated:
• Percuss posterior and lateral chest for resonance.
• Measure thorax for diaphragmatic excursion.
• Percuss costovertebral angle for tenderness.
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Guidelines:
Assess Posterior Chest (contd.)
• Auscultate posterior and lateral chest walls for breath
sounds.
• If adventitious sounds, assess for:
• Bronchophony.
• Egophony.
• Whispered pectoriloquy.
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Guidelines:
Assess Anterior Chest
• Move to front of patient; patient should lower gown
to waist.
• Inspect for skin color, intactness, lesions, and scars.
• Observe respiratory movement for symmetry, patient’s ease
with respirations, and posture.
• Observe precordium for pulsations or heaving.
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Guidelines:
Assess Anterior Chest (contd.)
• Palpate left chest wall to for point of maximum
impulse (PMI).
• If indicated:
• Palpate chest wall for fremitus, as with posterior chest.
• Percuss anterior chest for resonance.
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Guidelines:
Assess Anterior Chest (contd.)
• Auscultate anterior chest for breath sounds.
• Auscultate heart for rate, rhythm, S1/S2 (location, intensity,
frequency, timing, and splitting), S3, S4, or murmurs.
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Guidelines:
Assess Anterior Chest (contd.)
• Female breasts:
• Inspect for size, symmetry, contour, surface characteristics,
and breast or nipple deviation.
• Observe for symmetry of breast tissue during movement:
Arms over head, behind head, behind back; hands pushed
together tightly, patient leaning forward.
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Guidelines:
Assess Anterior Chest (contd.)
• Male breasts:
• Inspect for size, symmetry, breast enlargement, nipple
discharge, or lesions.
• All patients:
• Palpate lymph nodes associated with lymphatic drainage of
breasts and axillae.
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Guidelines: Assess Anterior Chest in
Recumbent Position
• Elevate patient’s head 45 degrees to inspect for
jugular vein pulsations.
• If indicated, measure jugular venous pressure for height
above sternal angle.
• Palpate anterior chest wall for thrills, heaves, and
pulsations.
• If indicated, measure blood pressure with patient
recumbent to compare with earlier reading.
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Guidelines: Assess Anterior Chest in
Recumbent Position (contd.)
• Female breasts:
• Provide chest drape for women; expose abdomen from
pubis to epigastric region.
• Inspect for symmetry, contour, venous pattern, skin color,
areolar area (note size, shape, and surface characteristics),
and nipples (note direction, size, shape, color, surface
characteristics, and discharge).
• Palpate breasts; note firmness, tissue qualities, lumps, areas
of thickness, or tenderness; areolar and nipple area.
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Guidelines:
Assess Abdomen
• Observe:
• Skin characteristics from pubis to midchest for scars,
lesions, vascularity, bulges, and navel.
• For movement of abdomen, peristalsis, and pulsations.
• Inspect abdominal contour.
• Auscultate abdomen (all quadrants) for bowel
sounds, bruits, and venous hums.
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Guidelines:
Assess Abdomen (contd.)
• Lightly palpate all quadrants for tenderness, guarding,
and masses.
• If indicated:
• Deeply palpate midline epigastric area for aortic pulsation
(AP).
• Percuss all quadrants and epigastric region for tone.
• Percuss upper and lower liver borders, and estimate liver
span.
• Percuss left midaxillary line for splenic dullness.
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Guidelines:
Assess Abdomen (contd.)
• If indicated, deeply palpate:
• Right costal margin for liver border.
• Left costal margin for splenic border.
• Abdomen for right and left kidneys.
• If indicated:
• Test abdominal reflexes.
• Assess abdomen for fluid.
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Guidelines:
Assess Abdomen (contd.)
• Patient raises head.
• Evaluate flexion/strength of abdominal muscles.
• Inspect for umbilical hernia.
• If indicated, lightly palpate inguinal region for lymph
nodes, femoral pulses, and bulges that may be
associated with hernia.
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Guidelines:
Assess Lower Extremities
• Patient remains recumbent; abdomen and chest
should be draped:
• Inspect legs, ankles, and feet for skin characteristics,
vascular sufficiency, hair distribution, and deformities.
• Palpate lower legs and feet for temperature, pulses,
tenderness, and deformities.
• If indicated, test range of motion, motor strength, and
sensation of hips, legs, ankles, and feet.
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Guidelines:
Assess Lower Extremities (contd.)
• If indicated:
•
•
•
•
Test for deep tendon reflexes.
Palpate hips for stability and tenderness.
Assess for knee effusion with bulge test or ballottement.
Assess for knee stability with drawer test, McMurray’s test,
or Apley’s test.
• Assess for hip flexion contracture with Thomas’s test.
• Assess nerve root compression with straight-leg raises.
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Guidelines: Assess Remaining
Neurologic System
• Observe patient moving from recumbent to sitting
position; note use of muscles, ease of movement,
and coordination.
• Assess gait: Observe and palpate spine for alignment
as patient stands and bends forward to touch toes.
• If indicated, evaluate hyperextension, lateral bending,
and rotation of upper trunk.
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Guidelines: Assess Remaining
Neurologic System (contd.)
• If indicated:
• Test sensory function by using light and deep (dull and
•
•
•
•
sharp) sensation.
Bilaterally test and compare vibratory sensation.
Test proprioception by moving toe up and down.
Test two-point discrimination.
Test stereognosis and graphesthesia.
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Guidelines: Assess Remaining
Neurologic System (contd.)
• If indicated:
• Test fine motor functioning and coordination of upper
extremities by instructing patient to perform at least two of
the following:
•
•
•
•
Alternate pronation and supination of forearm.
Touch nose with alternating index fingers.
Rapidly alternate finger movements to thumb.
Rapidly move index finger between nose and
examiner’s finger.
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Guidelines: Assess Remaining
Neurologic System (contd.)
• If indicated:
• Test fine motor functioning and coordination of lower
extremities; have patient run heel down tibia of opposite
leg.
• Evaluate Babinski’s sign and ankle clonus tests.
• Test for meningeal signs with Kernig’s and Brudzinski’s
signs.
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Guidelines: Assess Remaining
Neurologic System (contd.)
• If indicated, assess cerebellar and motor functions;
use at least two of the following:
• Romberg’s test (eyes closed).
• Walking straight heel-to-toe formation.
• Standing on one foot and then other (eyes closed).
• Hopping in place on one foot; then other foot.
• Knee bends.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum
• Male patient is recumbent, adequately draped.
• Inspect pubic hair for distribution and general characteristics.
• Inspect and palpate penis for color, tenderness, discharge, and
general characteristics.
• Inspect:
• Scrotum for texture and general characteristics.
• Sacrococcygeal and perianal areas and anus for
surface characteristics.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• Position patient lying on left side with right hip and
knee flexed.
• Palpate anal canal and rectum for surface
characteristics with lubricated gloved finger.
• Note characteristics of stool when gloved finger removed.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• If indicated, palpate anterior rectal surface for
prostate gland size, contour, consistency, mobility,
and tenderness.
• With patient standing, inspect inguinal canal for
bulges.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• Palpate testes, epididymides, and vas deferens for
location, consistency, tenderness, and nodules.
• If indicated:
• Transilluminate scrotum to assess for fluid and masses.
• Palpate inguinal canal to assess for hernias.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• Female patient should be lying in lithotomy position;
examiner should wear gloves.
• Inspect pubic hair for distribution.
• Inspect and palpate labia majora, labia minora, clitoris,
urethral meatus, vaginal introitus, perineum, and anus for
surface characteristics.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• If indicated:
• Palpate Skene’s and Bartholin’s glands for surface
characteristics.
• Inspect and palpate muscle tone for vaginal wall tone,
rectal muscle, and urinary incontinence.
• Insert vaginal speculum, and inspect surface characteristics
of vagina and cervix.
• Collect specimen for Papanicolaou (Pap) test and culture.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• If indicated:
• Perform bimanual palpation to assess form, size, and
characteristics of vagina, cervix, uterus, and adnexa.
• Perform vaginal-rectal examination to assess rectovaginal
septum and pouch, surface characteristics, and broad
ligament tenderness.
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Guidelines: Assess Genitalia, Pelvic
Region, and Rectum (contd.)
• If indicated:
• Perform rectal examination to assess anal sphincter tone
and surface characteristics; note characteristics of stool
when lubricated gloved finger removed.
• Patient resumes seated position; patient should have
gown on and be draped across lap.
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Question 1
During a complete head-to-toe examination, the nurse
will collect data about neurologic functioning by:
Observing the abdominal contour.
B. Observing breast symmetry.
C. Auscultating breath sounds.
D. Observing the patient sit up.
A.
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