Head-to-Toe Physical Health Assessment

You will use the course text to guide you in completion of a head to toe assessment. A comprehensive health assessment allows an overall view of your patient’s health status. As a registered nurse you must possess the knowledge and tools to promote a healthy and productive lifestyle.

DO A POWERPOINT PRESENTATION Please be sure to include substantial content on slides. YOU WILL PRETEND THAT YOU ARE DOING AN ASSESSMENT ON SOMEONE IN PERSON.

I HAVE ATTACHED A FORM TO USE AS A GUIDE FOR THE ASSESSMENT TO INCLUDE ON THE SLIDES
Student please START the recording and

verbally state this to the model before starting the assessment:

“Do you give verbal permission to participate as a model in this

assessment assignment and be recorded for school purposes for

Aspen University, class N495?”

– model must give a verbal “Yes” on camera to this question

before you begin.

“This assessment is indented to show my skills with the

assessment actions only and is not to be used as direction for your

health status or follow up with any irregular findings -do you

understand this?”

– model must give a verbal “Yes” on camera to this question

before you begin.

Aspen University

HEALTH ASSESSMENT AND PHYSICAL EXAMINATION

Student Name: Date:

Start Time: End Time: Total Time: (15 min or less)

Age of model: (cannot be under 18)

*If unable to procure equipment for any of the below, talk through the process. Assessment starts with Expected

Professional Behaviors and ends with the NEUROLOGICAL system on the final page.

ASSESSMENT RESULTS COMMENTS Vital Signs

• Temperature

• Pulse

• Respirations and SpO2 saturation

• Blood pressure- 2-step method

• Pain

ASSESSMENT COMMENTS Expected Professional Behaviors

• Washes hands in front of patient, gathers equipment

• Introduces self, role and purpose

• Two patient identifiers – first, last name, spell last name, birthdate

• General survey and LOC

Head, Face, and Neck

• Inspect: structures of head, face and neck

• Palpate: arteries (carotid & temporal)

• Palpate: for symptoms of TMJ

• Palpate: for enlargement of thyroid outside of trachea on each side

• Assess and palpate: trachea is mid-line

• Assess: Facial sensation (CN V – TRIGEMINAL) jaw clench or wisp test

• Assess: Facial symmetry at least 4 assessments (CN VII – FACIAL) raising eyebrows/closing eyes tight, smile/frown

• Assess: Speech quality (CN XII – Hypoglossal) “light, tight, dynamite”

• Palpate: Cervical Lymphatics posterior auricular, occipital, retropharyngeal, submandibular, submental, sublingual, superior superficial cervical, posterior superficial cervical, supraclavicular

Skin, Eyes, Ears, Nose, Mouth, and Throat

SKIN

• Inspect and palpate: skin – color, moisture and temperature

• Assess: Skin turgor

• Assess: CRT (capillary refill time)

• Assess and Palpate: Edema lower body (rank if present)

EYES

• External inspection-

• Assess: EOM’S (CN III – OCULOMOTOR, CN IV-TROCHLEAR, CN VI – ABDUCENS) – 6 Cardinal Fields of Gaze

• Assess: Peripheral vision – Confrontation test

• Assess: Corneal light reflex – “twinkle”

• Assess: PERRLA – Pupils are equal, round, reactive to light (with consensual response) and Accommodations (note convergence)

EARS

• External structures, color, drainage, tenderness (tragus non-tender/mobile)

• Internal structures – Tympanic Membrane (note appearance)

NOSE, MOUTH AND THROAT (Use tongue blade and penlight)

• Palpate: maxillary and frontal sinuses for tenderness

• Inspect: External nasal structures patency, appearance

• Inspect: Internal nasal passages (use light source) septum, swelling, etc.

• Inspect: Internal oral cavity – color, moisture, tongue, teeth, lesions (use light source)

• Assess: Uvula rises with phonation (CN IX – GLOSSOPHARYNGEAL) “ahh”

THORAX – Stethoscope on skin when assessing cleans stethoscope prior to use

• Assess: breathing for effort, approximate rate and quality

• Palpate: posterior chest for tenderness, masses (4 levels)

• Palpate: posterior chest for tactile fremitus “99” (4 levels)

• Percuss: posterior chest for potential consolidation (4 levels)

• Percuss: for CVA tenderness

• Auscultate: breath sounds posterior chest (6 levels) respiratory effort, no crackles, rhonchi, wheezes,

Anterior chest

• Auscultate: Carotids for bruits

• Auscultate: Breath sounds anterior chest (2 levels)

• Auscultate: heart sounds – verbalize 4 areas for auscultation (Aortic, pulmonic, tricuspid, mitral) Use diaphragm for S1, S2 sounds, Use bell for S3, S4, murmurs, etc

ABDOMEN

• Inspect: abdomen for contour, bulges, pulsations,

• Auscultate: abdomen for BS (bowel sounds) clicks, gurgles, BS x4

• Palpate: Light palpation 4 quadrants (approx. 3 x each quadrant)

EXTREMITIES

• Inspect and palpate: joints – wrists, elbows, shoulders, knees, ankles

• Assess: ROM and strength (against resistance) – grips, wrists, elbows, shoulders, neck and knees, ankles and pushes

• Palpate: pulses – radial, dorsalis pedis and posterior tibial (rank 0-4)

NEUROLOGICAL

• Observe: barefoot gait, heel to toe walk (standing)

• Assess: Romberg test – proprioception/balance (standing)

• Assess: DTR (deep tendon reflexes) 1 upper and 1 lower extremity

Upper: Brachioradialis reflex or Triceps reflex Lower: Patellar reflex or Achilles reflex (sitting)

• Assess: Cerebellar test – Rapid Alternating Movements (sitting)

Logical flow and sequencing

COMMENTS:

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