Complete Head-to-Toe Physical Assessment Script by S. Syed – Nursing Assessment Guide & Practice Checklist

Complete head to toe physical assessment scriptComplete
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head to toe physical assessment scriptComplete
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Complete Head-to-Toe Physical Assessment Script

Inspect NECK
GENERAL ORDER OF THE EXAM *
 Entire body  color, lesion, hair distribution Inspect
 Inspect  visually observe pt
 Finger/Toenails  pitting or clubbing  Obvious masses or pulsations
 Palpate  use hands to feel pt
 Describe lesions noting number, location,
 Percuss  light striking of body parts to Palpate
arrangement & type & document later
produce sounds
 Lymph nodes of head & neck; identify chains
 Auscultate  listening to body w/stethoscope Palpate (Use the back of the hand) 
o Bell = low-pitch sound
 Moisture, temperature, texture, turgor o Preauricular, postauricular, occipital
o Diaphragm = high-pitch sound o Tonsillar, submandibular, submental
*All systems except GI
(pinch back of hand), checking for tenting
 Note areas of tenderness or induration o Anterior cervical, posterior cervical &
4 CLASSICAL ASSUMPTIONS deep cervical (lean R/L)
 A & O x 4 (person, place, time, situation) o Supraclavicular, infraclavicular
 Vital signs WNL “I will continue to inspect the rest of the body o Non-palpable or <1cm, mobile, & non-
 Visual acuity assessed via Snellen chart bilaterally throughout the remainder of my tender
(CN 2 – Optic) exam”  Carotids  pulses
 Patient is in NAD  Trachea  deviation
 Thyroid  size, symmetry, tenderness,
PREPARATION HEAD  NCAT
consistency, nodules (palpate from behind)
 Knock on entry Inspect
 Introduce yourself  Skull  general size & contour
Neuro Test
“Hi, my name is Sumiyah, and I’m a  Scalp  lesions or inhabitants
o  CN 11 – Spinal Accessory (motor)  shrug
nursing student. I will be performing  Hair  quantity, texture, distribution, balding shoulders, turn head against resistance
a physical exam on you today.”  Face  symmetry (eyebrows, palpebral
 Hand hygiene fissures in line with helices of ears, nasolabial “CN 2 – 12 are intact”
folds)
GENERAL SURVEY
 Physical Appearance Palpate
o Age, sex, race/ethnicity  Skull  deformities or tenderness
 Body Structure  Temporal Artery  induration & intensity
o Tall/short (2+ = normal)
o Underweight/overweight/average weight  TMJ  pain, popping or crepitus
o Proportionality of weight to height (pt. open/close mouth)
 Mobility
o Ease in ambulation Neuro Test
o Ease in movement of limbs  CN 7 (Facial - motor)  pt. smile, frown,
 Behavior/Mood puff cheeks, resist eye opening
o Response to questions  CN 5 (Trigeminal - motor)  pt. clench jaw
o Grooming/hygiene – masseter muscle engaged
o Affect/speech/eye contact  CN 5 (Trigeminal - sensory)  light touch x6
Ex: “Pt is a (#) y/o (gender ident.) of avg. & (ask pt. close your eyes & say “now” when you
proportional height & weight, who moves easily feel it)
& responds to questions. They are well groomed “Pt is normocephalic – atraumatic”
& have appropriate affect to situation.”
SKIN
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, Complete head to toe physical assessment scriptComplete
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head to toe physical assessment scriptComplete
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Complete Head-to-Toe Physical Assessment Script

EYES  PERRLA & EOMI EARS
Inspect  Assess gross hearing
 External Inspection (CN 8 – Vestibular Cochlear)
o Eyelashes  point out & away o Normal conversation
o Conjunctiva/sclerae/cornea  clear & o Whisper test/finger rub
moist o Ask pt. to close their eyes & point
o Pupil  size & shape to the ear where they hear the
o (3-5mm b/l, round) finger rub
o If abnormal, continue to Weber
 3 Finger Test (midline) & Rinne (AC>BC) test
o Visual fields on confrontation Inspect
(CN 2 – Optic) (Jazz hands)  Auricle  symmetry, lesions, nodules
 Start laterally  Ask pt. stare  Special attention to back & top of ears as it is
straight in front & let me know a common site for skin cancer
when you see my fingers
o 6 cardinal fields of gaze (CN 3, 4, & 6 – Palpate
Oculomotor, Trochlear & Abducens)  Tragus & mastoid  tenderness
(Cat Whiskers)
 Ask pt. follow my finger & not Otoscopic Exam
move your head  Maneuver Auricle
o Accommodation & Convergence o Adults Pinna  up & back
(CN 2 & 3) (Follow Finger) o Peds Pinna down & back
 Ask pt. to follow my finger as I  Inspect canals  cerumen (ear wax), foreign
bring it closer to pt. face & away bodies, inflammation, discharge
 Inspect TM & note presence of the
 2 Light Test (Pen light) following/abnormalities
o Direct (CN 2) constrict & consensual o Not bulging or retracted
(CN 3) light reflexes, consensually o Pearly gray color
constricts
o Bony prominences
o Corneal light reflex  strabismus
o Cone of light (R ‘ 5; L ‘ 7)
(shine light & see that the light falls in the
same place in both eyes)

 1 Ophthalmoscope Exam
(Right Eye to Right Eye)
o Catch red light reflex & move closer into
pt.
o Optic disc  clear, well defined, creamy
yellow
o 4 sets of retinal vessels
o Macula  2 optic discs away
“Pt is PERRLA & EOMI - Pupils are equal,
round, reactive to light & accommodation ;
Extra ocular movements intact”
Complete head to toe physical assessment scriptComplete
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head to toe physical assessment scriptComplete
s syed.(exthttps://online2pdf.com/remove-pdf-header-footer)
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