Head to Toe Assessment
Perform Hand Hygiene and Provide Privacy to patient
PRESENT YOURSELF
-Hello, my name is Randy Chavez and I need to perform a head to toe assessment on you.
Is that ok with you?
LOOK AT
...
Head to Toe Assessment
Perform Hand Hygiene and Provide Privacy to patient
PRESENT YOURSELF
-Hello, my name is Randy Chavez and I need to perform a head to toe assessment on you.
Is that ok with you?
LOOK AT PATIENT’S ARM BAND
- (This will help you to have the right patient)-
-Ask Patient all personal information in the Band to help you check their NEUROSTATUS
-Can you tell me where we at?
-Can you tell me what we are doing today?
-Can you tell me who is the President of the U.S?
(If Patient responds to all questions correctly, you can say that patient is ORIENTED AND ALERT x
3)
VITAL SIGNS
-Heart rate (60-100 bpm)
-Blood Pressure (119/79)
-Temperature (98.6)
-Oxygen Saturation (75-100 mm of mercury)
-Respiratory Rate (12-20 Breaths per minute)
-Patient Pain Rate
Ask Patient: -Are you having any pain on a scale of 0-10, zero for the less
pain and 10 for the worse pain you have ever had?
COLLECT HEIGHT, WEIGHT, BMI
BMI: -less than 18.5 (underweight)
-more than 30 (obese)
WHY WE ASK ALL THESE QUESTIONS?...
-Why are we asking all these questions and
taking vital signs to the patient?
A/ The meaning of all done above is to collect
all information from the patient and check for:
-Patient’s Emotional Status: (are they calmed,
agitated, drowsy?), in fact just to see what’s
going on with the patients.
-To check if they look their stated age.
-To check if the skin color matches their
ethnicity?
-To check if they understand all the questions
and see if they can hear well, or if is a delay
on their responses.
-To notice while talking any masses, lesions,
amputations, skin sweaty.
-To check if their hygiene is good?
-To check if their posture is good?
-To check for any abnormal smell.
Then move on to HEAD
First, Inspect the head.
1
Downloaded by John Mixer (
[email protected])
lOMoARcPSD|2843306
HEAD TO TOE ASSESSMENT GUIDE
Look for Skin Color
o If is nice and pink?
Check that head is in size with the body
Check for any abnormal or twitching of the face that Patient cannot control by himself or
does involuntary
Check that face is symmetrical (like bell’s palsy and people with Stroke)
Look for Eyes on the Same Level
Look at facial Expressions and check CRANIAL NERVE # VII (7) FACIAL, performing a facial
nerve check.
HOW TO CHECK THE NERVE #7
-ASK patient: Close your eyes tightly and open them up.
-ASK patient: Smile for me
-ASK patient: Round for me
-ASK patient: Pop out your cheeks
Palpate the HEAD. (Cranium)
--Wearing gloves:
-Check for any masses, indentations, or infestations
-Check for Skin Breakdown
-Check inside the Hair (for lies) or baldness (alopecia)
Find Temporal Artery and feel them bilaterally.
While in that area, Check for CRNIAL NERVE # V (5) TRIGEMINAL. (responsible for
mastication and some movements)
HOW TO CHECK THE NERVE #5
-ASK patient: to bite down hard and feel the temporal muscle and mystical muscle.
-ASK patient: Try to open mouth over resistance.
Inspect and Palpate Sinuses by putting pressure
-ASK the patient: Do you feel any pain when I press here?
Then move to the EYES
Check the eyelids, pupils, sclera, conjunctiva, and iris.
Check for EYE LIDS Swollenness.
Check for Sclera (should be white). If yellow, suspect Jaundice
2
Downloaded by John Mixer (
[email protected])
lOMoARcPSD|2843306
HEAD TO TOE ASSESSMENT GUIDE
Check Conjunctiva
-ASK patient: To look up. (Should be nice and pink)
Check EYE SOCCERS.
-Are they equal?
-Are there any strabismus?
Check Pupils
-Are there any Anisocoric? (one pupil bigger than the other one)
Check for Pupil Measurement.
-Normal Measurement should be 3-5 mm
While there, Check for CRANIAL NERVE #3 (OCULOMOTOR), #4 (TROCHLEAR), #6 (ABDUCENS)
HOW TO CHECK CRANIAL NERVES #3, #4, #6
-Get a penlight and move as 6 cardinal fields of Gaze (picture below).
-Look for any involuntary shaking of the eyes while following the penlight.
Check how reactive Pupils are to light.
-Pupils should constrict the same on both eyes when presenting light.
-If pupil normal measurement is 3 mm, should constrict to 1 mm
Check for Pupil Accommodation
-ASK patient: to stare at your penlight and move it towards the midline of both eyes.
-Eyes should cross and pupils should constrict
When Documenting this exam, you should say that PUPILS are:
P- pupils are
E- equal
R- round and reactive to
L- light
A-and accommodate
Then move to EARS
Inspect ears for abnormalities, redness, drainage
Ask patient: Are you having any pain?
Check for Tophi.
3
Downloaded by John Mixer (
[email protected])
lOMoARcPSD|2843306
HEAD TO TOE ASSE
 Head To Toe Assessment Guide.png)
