Program Script. Nursing Assessment The Head-to-Toe Assessment
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1 Program Script Nursing Assessment The Head-to-Toe Assessment This document comprises the complete script for this program including chapter titles. This is provided to instructors to enhance the educational value of the program and to provide a navigation guide.
2 The previous programs in this series illustrated detailed assessment of the various body systems. In this program we will put it all together in the form of an overall initial head-to-toe assessment that would be utilized when admitting a new patient to either inpatient or outpatient care. Male and female reproductive and breast assessment will not be included as these are specialty exams, and they have been fully covered in other programs in this series. As in the systems based assessment, begin by taking a medical history, including previous health problems, current conditions and concerns, and medications. As you gather the history, also note if the patient appears to be the stated age, exhibits normal or impaired level of consciousness, whether or not he appears appropriately nourished. Also note his ability to communicate appropriately and effectively. If the person speaks a different language, make arrangements for interpreter services. Finally, note the patient s level of personal hygiene as an indication of his ability to provide for his own care needs. Provide the patient with a gown and privacy to change. Once the patient is ready, begin by taking basic height, weight and circumference measurements. These measurements allow the nurse to calculate the patient s body mass index. Vital signs pulse and blood pressure are taken next, and if the patient has been seen before, compared with previous readings. Page 2 AccessPortal 2014
3 It is important to take and record the blood pressure reading on both arms, as a significant variance can indicate circulatory problems. Once the basic measurements and vital signs have been taken, the assessment begins with the patient s head and proceeds to his toes as the phrase, Head-to-Toe, implies. During this process, examine the patient s skin at each step of the assessment. The nurse will check the scalp, head, and hair, palpate the maxillary and frontal sinuses for tenderness, the temporomandibular joint for tenderness and crepitus, and the lymph nodes along the jaw line for swelling or tenderness. If the patient complains of pain at any point in the exam, a pain assessment would be done. The eye exam includes visualizing the conjunctiva, sclera, and iris. Pupillary reflexes are checked next, followed by the six cardinal points of gaze. Have patient cover one eye and read the smallest line he can see. Repeat on the other eye. Inspection of the ears includes noting their position on the head, alignment to one another, skin condition, and auditory meatus. Check for tenderness related to movement of the pinna. Using the otoscope, inspect the ear canals. Inspect external nose and nares, noting shape, symmetry, and the presences or absence of visible lesions. Visually inspect the nasal passages. Page 3 AccessPortal 2014
4 Test nasal patency by having the patient occlude one nostril to see if there is good air movement through the other. This is done on both sides. Ask patient if he has any problem with recurring nasal congestion. Use a penlight to inspect the oral cavity, buccal mucosa, teeth, gums, tongue, floor of mouth, palate, and uvula. Use a tongue blade to aid in visualization of the sides of the mouth. Have patient say ah as you observe movement of the uvula and the appearance of the back of the throat. Palpate the neck for any enlarged lymph nodes. Next, palpate the trachea to see it is midline. Finally, palpate the carotid pulses, one at a time. When checking carotid pulses, always use gentle pressure to avoid occluding them. Test for neck range of motion by having the patient move his head in a circular fashion. Then check the strength of neck muscles by asking the patient to push against your hand. Next have him lower his gown to expose the trunk. Inspect the skin, note any sun damage or lesions, and palpate surface for pain or lumps. Move to the shoulders and inspect them for configuration. Perform the shrug strength test. Then palpate along the clavicles, noting any pain or misalignment. Inspect the arms, wrists and hands for sun damage and dermatological abnormalities. Now ask him to demonstrate the range of motion of his shoulders, elbows and wrists. Note any pain or restriction of movement. Page 4 AccessPortal 2014
5 Using your stethoscope, perform lung auscultation listening over the lung fields on the chest and again on the back. Note any adventitious lung sounds. Next auscultate the chest for heart sounds. Note any murmurs or irregularities in the rate or rhythm. Assist the patient as necessary to assume a supine position for the abdominal exam. Expose the abdomen and inspect the skin. Next auscultate for bowel sounds. Finally, palpate for pain and tenderness and note any swelling that could indicate hernia. With the patient still supine, inspect skin and configuration of the legs and feet. Note any varicosities. Assess pedal pulses. Now verbally guide your patient as he demonstrates active range of motion of his hips, knees, ankles and feet. Note any weakness or restriction in movements. If your patient is unable to perform active ranging of these joints, assess movement by performing passive range of motion. Assist him to again sit with legs dangling and assess the deep tendon reflexes at the knee. Conclude the assessment with a brief neurologic assessment. Have him close his eyes and touch his index finger of one hand and then the other to his nose. Ask the patient to perform the toe-to-heel walk. Alternatively, you can test balance by having close his eyes and balance on one foot. Conclude your exam by asking the patient if he has any questions and thanking him for his cooperation. The head-to-toe assessment is intended to screen patients for clues to health problems. A more detailed assessment may be indicated by abnormalities found, and these should always be documented and reported. Page 5 AccessPortal 2014
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