Name: ______________________________ Date: ____________ Section/Group: __________

Head to Toe Assessment

CHECKLIST
Legend:
3 – Very Satisfactory 0 – Did Not Perform the Procedure
2 – Satisfactory 1 – Needs Improvement
PROCEDURES 3 2 1 0

Explain to the client what you are going to do, why is it necessary, and how
he can cooperate.

Wash hands and observe appropriate infection control procedures.

Provide for client privacy.

Determine the health history of the patient.

Conduct the general survey, (physical appearance, psychological presence

and signs of distress).

Get the anthropometric measurement (height, weight, body mass index,

waist-to-hip ratio, skin fold thickness, mid-arm circumference)

Get the vital signs.

Conduct the head to toe assessment.

Head:

Inspect the evenness of growth over the scalp. Inspect hair thickness or
thinness. Inspect hair texture and oiliness. Note presence of infections or
manifestations by parting the hair in several areas and checking behind the
ears and along the hairline at the neck. Inspect the amount of body hair.

Palpate the head for the presence of lesions.

Inspect the facial features. Note symmetry of facial movements. Let the
patient frown, smile, clench his jaw and puff cheeks.

Determine the sensory function of the facial nerve by stroking cotton ball
into the different areas of the face and do the sharp/dull or sharp/soft test.
If necessary, perform the hot/cold test.

Palpate the temporal artery and note the rate, rhythm, volume and
symmetry. Auscultate to determine any bruit.

Eyes

Inspect the eyebrows for hair distribution and alignment and for skin quality
and movement. Inspect the eyelashes for evenness of distribution and
direction of curl.

Assess the visual acuity by determining the distance and near vision.

Inspect and palpate the lacrimal gland.

Inspect the cornea for clarity and texture. Ask the client to look straight
ahead. Hold a penlight at an oblique angle to the eye, and move the light
slowly across the corneal surface.

Perform the corneal sensitivity (reflex) test to determine the function of the
fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and
look straight ahead. Approach from behind and beside the client, and
lightly touch the cornea with a cotton ball.
Inspect the pupil’s color, shape, and symmetry of size.

Assess each pupil’s direct and consensual reaction to light and

accommodation.

Assess peripheral visual fields.

Assess six ocular movements to determine eye alignment and

coordination.

Ears

Inspect the auricles for color, symmetry of size, and position.

Palpate the auricles for texture, elasticity and areas of tenderness.

Perform the voice whisper test.

Perform the Weber test.

Perform the Rinne test.

Nose

Inspect the external nose for any deviations in shape, size or color and
flaring or discharge from the nares.

Lightly palpate the external nose to determine any areas of tenderness,

masses and displacements of bone and cartilage.

Determine the patency of both nasal cavities. Ask the patient to smell
different kind of scents.

Inspect the nasal cavities using a flashlight or a nasal speculum. Observe

for the presence of redness, swelling and discharge. Inspect the nasal
septum between the nasal chambers.

Palpate and percuss the sinuses.

Mouth

Don gloves.

Inspect the outer lips for symmetry of contour, color and texture. Inspect
and palpate the inner lips and buccal mucosa for color, moisture, texture,
and the presence of lesions. Inspect the teeth and gums while examining
the inner lips and buccal mucosa.

Inspect the surface of the tongue for position, color and texture.

Inspect tongue movement. Ask the client to roll the tongue upward and
move it from side to side.

Ask the client to place the tip of his tongue against the roof of the mouth.
Inspect the base of the tongue, the mouth floor and the frenulum.

Use a piece of gauze to grasp the tip of the tongue and with the index
finger of your other hand, palpate the back if the tongue, its borders and its
base. Palpate the tongue and the floor of the mouth for any nodules, lumps
or excoriated areas.

Inspect the hard and soft palate for color, shape and texture and the
presence of bony prominences. Ask the client to open his mouth wide and
tilt his head backward. Then, depress tongue with a tongue blade as
necessary, and use a penlight for appropriate visualization.

Inspect the uvula for position and mobility while examining the palates. To
observe the uvula, ask the client to say “ah” so that the soft palate arises.

Inspect the oropharynx for color and texture. Inspect one side at a time to
avoid eliciting the gag reflex. To expose one side of the oropharynx, press
a tongue blade against the tongue on the same side about halfway back
and opens the mouth wide. Use a penlight for illumination, if needed.
Inspect the nostrils for color, discharge and size.

Elicit the gag reflex by pressing the posterior tongue with a tongue
depressor.

Let the patient taste different flavors.

Remove gloves and wash hands.

Neck

Inspect the neck muscles (sternocleidomastoid and trapezius) for abnormal

swelling or masses. Ask the client to hold her head erect.

Observe head movement. Ask the client to: Move her chin to the chest
(determines function of the sternocleidomastoid muscle); Move her head
back so that the chin points upward (determines the functions of the
trapezius muscle); Move her head so that the ear is moved toward the
shoulder on each side (determines the function of the sternocleidomastoid
muscle) Turn her head to the right and to the left (determines the function
of the sternocleidomastoid muscle).

Assess muscle strength. Ask the client to:

Turn her head to one side against the resistance of your hand. Repeat with
the other side.

Shrug the shoulders against the resistance of your hands.

Palpate the entire neck for enlarged lymph nodes.

Inspect, palpate and auscultate carotid pulse.

Inspect and determine for the presence of jugular vein distention.

Palpate the trachea for lateral deviation. Place your fingertip or thumb on
the trachea in the suprasternal notch, and then move your finger laterally to
the left and the right in spaces bordered by the clavicle, the anterior aspect
of the sternocleidomastoid muscle and the trachea.

Inspect the thyroid gland. Stand infront of the client. Observe the lower half
of the neck overlying the thyroid gland for symmetry and visible masses.
Ask the client to hyperextend her head and swallow. If necessary, offer a
glass of water to make it easier for the client to swallow.

Palpate the thyroid gland for smoothness. Note any areas of enlargement,
masses or nodules.

If enlargement of the gland is suspected: Auscultate over the thyroid area

for a bruit.

Thorax and Lungs

Posterior Thorax
Inspect the shape and symmetry of the thorax from posterior and lateral
views. Inspect the spinal alignment for deformities.

Have the client stand. From a lateral position, observe the three normal
curvatures: cervical, thoracic and lumbar. To assess for lateral deviation of
spine (scoliosis), observe the standing client from rear. Have the client
bend forward at the waist and observe from behind.

Palpate the posterior thorax. Palpate the posterior chest for respiratory
excursion. Place the palms of your both hands over the lower thorax, with
your thumbs adjacent to the spine and your fingers stretched laterally. Ask
the client take a deep breath while you observe the movement of your
hands and any lag in movement.

Palpate the chest for vocal (tactile) fremitus. Ask the client repeat such
words as “blue moon” or “one, two, three” or “ninety nine”.

Percuss the thorax. Percuss for diaphragmatic excursion.

Auscultate the chest using the flat-disc diaphragm of the stethoscope. Use
the systematic zigzag procedure used in percussion. Ask the client to take
slow, deep breathe through the mouth. Listen at each point to breath
sounds during a complete inspiration and expiration. Compare findings at
each point with the corresponding point on the opposite side of the chest.

Anterior Thorax

Inspect breathing patterns.

Palpate the anterior chest for respiratory excursion.

Palpate for vocal (tactile) fremitus.

Percuss for diaphragmatic excursion.

Auscultate the chest using the flat-disc diaphragm of the stethoscope.

Heart

Auscultate the heart rate at the point of maximal impulse (PMI)

Assess for the presence of murmurs, S3, S4 sounds

Auscultate other valves.

Breast and Axilla

Inspect breast size, contour, presence of retractions, etc.

Do the breast exam accurately.

Palpate for lymph node enlargement especially at the tail of Spence.

Abdomen

Inspect the skin of the abdomen noting for lesions.

Auscultate borborygmy sounds, and peritoneal friction rubs using the

systematic way.

Palpate for the liver and bladder.

Percuss all areas of the abdomen using the systematic process.

Upper Extremities
 Do the musculoskeletal assessment. Test for the muscle strength.

Assess for sensations to temperature, pain and touch.

Palpate the radial pulse and reports the rate and quality.

Assess for the nails and capillary refill.

Lower Extremities

Do the musculoskeletal assessment of the lower extremities. Test for the

muscle strength.

Assess for sensations to temperature, pain and touch.

Palpate the pedal pulse and reports the rate and quality.

Assess for the nails and capillary refill.

For the next items, evaluate the students in general according to the criteria. (5 as the
highest score)
5 4 3 2 1

Mastery

Orderliness

Proper attitude in assessing the client followed.

Ability to answer questions.

Proper reporting observed.

Student’s Signature: ____________________

Evaluator’s Signature: ____________________

Comments:__________________________________________________________________
_______________________________________________________________.