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Complete Head to Toe Assessment
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Complete Head to Toe Assessment
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Complete Head-to-Toe PhysicalAssessment Cheat Sheet
Nursing assessment is an important step of the whole nursing process. Assessment can be
called the “base or foundation” of the nursing process. With a weak or incorrect assessment,
nurses can create an incorrect nursing diagnosis and plans therefore creating wrong
interventions and evaluation. To prevent those kind of scenarios, we have created a cheat
sheet that you can print and use to guide you throughout the first step of the nursing process.
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul
odor. He has a good skin turgor and skin’s temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable
amount of body hair. There are also no signs of infection and infestation observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is
smooth and is intact with the epidermis. When nails pressed between the fingers
(Blanch Test), the nails return to usual color in less than 4 seconds.
Head
Head: The head of the client is rounded; normocephalic and symmetrical.
Skull: There are no nodules or masses and depressions when palpated.
Face: The face of the client appeared smooth and has uniform consistency and with
no presence of nodules or masses.
Eyes and Vision
Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned
and showed equal movement when asked to raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
Eyelids: There were no presence of discharges, no discoloration and lids close
symmetrically with involuntary blinks approximately 15-20 times per minute.
, Eyes
o The Bulbar conjunctiva appeared transparent with few capillaries evident.
o The sclera appeared white.
o The palpebral conjunctiva appeared shiny, smooth and pink.
o There is no edema or tearing of the lacrimal gland.
o Cornea is transparent, smooth and shiny and the details of the iris are
visible. The client blinks when the cornea was touched.
o The pupils of the eyes are black and equal in size. The iris is flat and round.
PERRLA (pupils equally round respond to light accommodation),
illuminated and non-illuminated pupils constricts. Pupils constrict when
looking at near object and dilate at far object. Pupils converge when
object is moved towards the nose.
o When assessing the peripheral visual field, the client can see objects in the
periphery when looking straight ahead.
o When testing for the Extraocular Muscle, both eyes of the client
coordinately moved in unison with parallel alignment.
o The client was able to read the newsprint held at a distance of 14 inches.
Ears and Hearing
Ears: The Auricles are symmetrical and has the same color with his facial skin. The
auricles are aligned with the outer canthus of eye. When palpating for the texture,
the auricles are mobile, firm and not tender. The pinna recoils when folded. During
the assessment of Watch tick test, the client was able to hear ticking in both ears.
Nose and Sinus
Nose: The nose appeared symmetric, straight and uniform in color. There was no
presence of discharge or flaring. When lightly palpated, there were no tenderness
and lesions
Mouth:
o The lips of the client are uniformly pink; moist, symmetric and have a
smooth texture. The client was able to purse his lips when asked to
whistle.
o Teeth and Gums: There are no discoloration of the enamels, no retraction
of gums, pinkish in color of gums
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