Head to Toe Assessment Checklist

Head

You will want to examine the head for discomfort or abnormalities. Things to look for during the head assessment include:

• Inspection with your eyes to check for any signs of asymmetry, or edema
• Inquiring about any pain or discomfort
• Examining the facial nerve by asking the patient  to smile and raise their eyebrows
• Touching (palpation) for any tenderness or edema

Neck

Use your eyes to visually examine the patient’s neck, and use your hands to carefully palpate the area to look for any signs or symptoms. Assessment of the neck should include:

• Assessment of the patient’s spinal accessory nerve while asking the patient to shrug their shoulders. Abnormalities can be found during this assessment.
• Inspecting any limited range of motion in the neck by having the patient rotate their head in various directions
• Palpating the neck for swelling or enlarged lymph nodes or glands
• Inspection of the patient‘s neck for a tracheal deviation.
• Noting any signs of an enlarged thyroid gland by palpating while the patient swallows some water.

Eyes

Assessment of the eyes include:

• Inspecting the sclera, assessing for signs of discharge, redness, lesions, or other abnormalities
• Inspection of the pupils with a pen light to check the pupillary response to light and movement. (PERRLA=pupils equal, round, reactive to light and accommodation) Also noting the size of the pupils as well.
• Inspection of the patient’s six extraocular eye muscles to determine how well they are working along with cranial nerves, III, IV, and VI.
• Using a visual acuity test to see how the optic nerve performs

Nose and Sinus

Examining the nose and sinuses can assess any issues with smell, potential sinus infections, or other damage to the area. Tips for examining the nose and sinus area include:

• Using your otoscope to examine the inside of the nose also while Inspecting the septum
• Palpate the sinuses for tenderness
• Use scented objects to test the olfactory nerve for smell
• Checking for signs of discharge or nasal polyps

Ears

Recommendations for assessing the ears include:

• Inspection of the outer and inner ear
• Palpate for any tenderness
• Utilize an otoscope to assess the cone of light
• Assess for signs of lesions, discharge, bulging, or any inner scarring
• Perform the whisper test to see the function of the vestibulocochlear nerve

Mouth and Throat

Ask your patient to open their mouth to closely examine the mouth and throat. Upon examination of the throat and mouth, inspect the following:

• Signs of swelling of the lips, tonsils, uvula, or elsewhere in the mouth
• Lesions or other abnormalities of the mucosa
• Cracked or dried lips or other signs of dryness
• A hairy tongue
• Ask the patient if they have had any difficulty with tasting foods, swallowing, or gagging.

Chest

The chest area can provide valuable insight into the patient’s respiratory and cardiovascular health. Assessment of the cardiovascular and respiratory system includes:

• Inspect any visual chest defects.
• Auscultate heart sounds that indicate an abnormal heartbeat, such as a murmur.
• Auscultate the apical pulse at the point of maximum impulse.
• Auscultate lung sounds in all fields (anterior, posterior, and lateral), listening for normal vs abnormal breath sounds. Be aware of crackles, wheezes, stridor.
• Inspect the rise and fall of the chest. Looking for abnormal findings, such as intercostal retractions. (Are the respirations labored?)

Abdomen

To assess the abdomen properly, you must first inspect. Next, you will auscultate before any palpation or percussion to avoid disturbing bowel sounds. If the patient is experiencing abdominal pain, they will guard the abdomen, and likely you will not get a chance to auscultate. Tips for examining the abdomen include:

• Looking for new or differing skin pigmentation.
• Checking for tenderness.
• Looking for any signs of protrusions.
• Using auscultation to see if you hear abnormal bowel sounds in any of the four abdominal quadrants. If no bowel sounds are present, you must auscultate all four abdominal quadrants for five minutes each before charting no bowel sounds.
• Inspecting any abdominal pulsations.
• Inquiring about signs of gastrointestinal health, such as abnormal bowel movements, as well as the last bowel movement.

Pulses and Vascular

The patient’s pulses can provide valuable information about overall health. The following pulses should be assessed (palpated ) in a head to toe assessment: temporal, carotid, apical (with cardiac), brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulse. Things to look for when assessing the veins and pulses include:

• Palpating and document pulses. Prompt intervention for absent pulses.
• Observing any signs of arterial or venous disease
• Inspecting the skin for discolorations
• Checking for signs that the capillaries are not refilling properly

Extremities and the Musculoskeletal System

Assessment of the musculoskeletal system involves a range of motion (active or passive) and strength of extremities. An extremity and musculoskeletal system assessment will likely include:

• Assessment of difficulty independently moving upper or lower extremities.
• Assessment of strength in the upper and lower extremities.
• Examining the patient to see if they can identify sharp and dull sensations on their extremities
• Inspecting signs of abnormalities in the fingernails and toenails

Neurological

You also need to closely examine the patient’s mental state for signs of delay or confusion. Assessment of the neurological state includes:

• Inspecting  the patient’s balance
• Assessing the patient”s  gait while having them walk across the room heel to toe
• Testing the patient’s reflexes for normal vs abnormal findings.

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