NSG316 HEAD TO TOE ASSESSMENT
Expected Professional Behaviors: Gathers equipment and cleans stethoscope -
Answers :Take the PBA box and have your pen light and stethoscope in place. You do
NOT need to verbalize you have gathered your equipment but it should be obvious that
you have gathered the proper supplies.
Expected Professional Behaviors: Washes hands in front of client - Answers :Must use
hand sanitizer in room in front of client.
Expected Professional Behaviors: Introduces self, role, and purpose. Ask consent for
examination - Answers :"Hello, my name is _________ and I'll be your student nurse. I
would like to complete a head-to-toe assessment. Is that okay with you?" (wait for their
agreement) "Thank you."
Expected Professional Behaviors: Identifies client with two identifiers - First, last name,
birthdate. Asks for allergies - Answers :Check wrist/ID band. "For your safety, can you
confirm your first and last name? What is your birthdate? Do you have any allergies?
Expected Professional Behaviors: Provides privacy - Answers :Pull curtain for privacy.
Mental Status Assessment: Alert - Answers :Verbalize: The patient is alert and
responsive to questions.
Mental Status Assessment: Oriented: Person, place, time. - Answers :"Thank you for
confirming your name and birthdate. Can you identify where we are right now? What is
today's date?" Verbalize:"Client is alert and oriented x3—person, place, and time."
Skin: Inspects and palpates: Skin - Color, lesions, scars, tattoos. - Answers :Inspect
skin on face, neck, arms, and legs and touch the skin with the back of your hand to
assess skin temperature. You will need to lift the pant legs (if wearing long pants) to see
and palpate skin on lower extremities. Verbalize: "Skin is warm, dry, and intact, color is
consistent throughout. No lesions, scars or tattoos are noted on exposed skin."
Skin: Assesses: Skin turgor. - Answers :Test skin turgor on torso bilaterally (inform pt).
Verbalize: "Skin turgor is appropriate bilaterally. No tenting noted."
Assesses and palpates: Edema upper body (if present). - Answers :Palpate for upper
body edema on arms. Verbalize: "No upper body edema noted bilaterally."
Skin: Palpate radial pulse, rank 0-3 - Answers :Assess radial pulse verbalize: "Pulses
are strong, equal and palpable bilaterally, approximately _____+."
Skin: Assesses: CRT (capillary refill time) one finger bilaterally - Answers :Press one
finger or thumb briefly on each hand. While releasing your hand, note the capillary refill
time.
, Verbalize: "Capillary refill is less than 2 seconds bilaterally."
HFN: Inspects: Structures of head, face, neck, and hair. - Answers :Examine
head/face/neck. Verbalize: "Head is a normocephalic shape, face is symmetrical, neck
is proportionate to the head and face and hair distribution is normal".
HFN: Palpates: Arteries (carotid and temporal). - Answers :Palpate temporal arteries
bilaterally and simultaneously. Palpate carotid arteries bilaterally but one at a time.
Verbalize: "Temporal and carotid arteries are palpable bilaterally."
HFN: Palpates: Maxillary and frontal sinuses for tenderness. - Answers :Palpate both
sinuses bilaterally (identifying location—maxillary or frontal during palpation) and ask
client if there is tenderness in either area. Verbalize: "No tenderness in maxillary or
frontal sinuses bilaterally."
HFN: Palpates: For symptoms of TMJ (pain, clicking, popping). - Answers :"I am going
to put my hands on both sides of your jaw and have you open and close your mouth. Do
you have any pain, clicking, or popping when you do this?" Verbalize: "Client denies
pain; no popping or clicking noted bilaterally."
HFN: Palpates: Cervical lymphatics (6 total)
Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental. -
Answers :Palpate lymph nodes bilaterally, asking client to identify if there is any pain.
Identify location as you palpate.
Verbalize:"Lymph nodes are non-palpable and non-tender bilaterally."
HFN: Assesses and palpates: Trachea is mid-line - Answers :Facing patient, inspect
and gently palpate trachea. Verbalize: "Trachea is midline."
HFN: Assesses: Facial motor/sensation (CN V - TRIGEMINAL) jaw clench/wisp test. -
Answers :Must state the Cranial Nerve NUMBER and NAME for credit.
"I'm going to test your cranial nerves. First can you clinch your jaw? (client clinches
jaw). Now relax. Next, with your eyes closed, I'm going to touch you with this cotton ball
on the face. Please point to or tell me where you feel it on either side (right cheek, left
forehead, etc.)."
Have patient close their eyes and use the cotton swab/ball on forehead, cheek and
chinbilaterally."Thank you."Verbalize:"Cranial Nerve V, Trigeminal, is intact."
HFN: Assesses: Facial symmetry at least four assessments (CN VII - FACIAL).
Puffing checks, raising eyebrows/closing eyes tight, smile/frown. - Answers :"Next, we
are going to test your facial nerves. Can you puff both cheeks? Raise your eyebrows?
Close your eyes tight? Can you smile? And frown?"
Verbalize:"CN VII—Facial, is intact."
HFN: Assesses: Speech quality (CN XII - Hypoglossal) "light, tight, dynamite." -
Answers :Ask patient to say, "Light, Tight, Dynamite."
Expected Professional Behaviors: Gathers equipment and cleans stethoscope -
Answers :Take the PBA box and have your pen light and stethoscope in place. You do
NOT need to verbalize you have gathered your equipment but it should be obvious that
you have gathered the proper supplies.
Expected Professional Behaviors: Washes hands in front of client - Answers :Must use
hand sanitizer in room in front of client.
Expected Professional Behaviors: Introduces self, role, and purpose. Ask consent for
examination - Answers :"Hello, my name is _________ and I'll be your student nurse. I
would like to complete a head-to-toe assessment. Is that okay with you?" (wait for their
agreement) "Thank you."
Expected Professional Behaviors: Identifies client with two identifiers - First, last name,
birthdate. Asks for allergies - Answers :Check wrist/ID band. "For your safety, can you
confirm your first and last name? What is your birthdate? Do you have any allergies?
Expected Professional Behaviors: Provides privacy - Answers :Pull curtain for privacy.
Mental Status Assessment: Alert - Answers :Verbalize: The patient is alert and
responsive to questions.
Mental Status Assessment: Oriented: Person, place, time. - Answers :"Thank you for
confirming your name and birthdate. Can you identify where we are right now? What is
today's date?" Verbalize:"Client is alert and oriented x3—person, place, and time."
Skin: Inspects and palpates: Skin - Color, lesions, scars, tattoos. - Answers :Inspect
skin on face, neck, arms, and legs and touch the skin with the back of your hand to
assess skin temperature. You will need to lift the pant legs (if wearing long pants) to see
and palpate skin on lower extremities. Verbalize: "Skin is warm, dry, and intact, color is
consistent throughout. No lesions, scars or tattoos are noted on exposed skin."
Skin: Assesses: Skin turgor. - Answers :Test skin turgor on torso bilaterally (inform pt).
Verbalize: "Skin turgor is appropriate bilaterally. No tenting noted."
Assesses and palpates: Edema upper body (if present). - Answers :Palpate for upper
body edema on arms. Verbalize: "No upper body edema noted bilaterally."
Skin: Palpate radial pulse, rank 0-3 - Answers :Assess radial pulse verbalize: "Pulses
are strong, equal and palpable bilaterally, approximately _____+."
Skin: Assesses: CRT (capillary refill time) one finger bilaterally - Answers :Press one
finger or thumb briefly on each hand. While releasing your hand, note the capillary refill
time.
, Verbalize: "Capillary refill is less than 2 seconds bilaterally."
HFN: Inspects: Structures of head, face, neck, and hair. - Answers :Examine
head/face/neck. Verbalize: "Head is a normocephalic shape, face is symmetrical, neck
is proportionate to the head and face and hair distribution is normal".
HFN: Palpates: Arteries (carotid and temporal). - Answers :Palpate temporal arteries
bilaterally and simultaneously. Palpate carotid arteries bilaterally but one at a time.
Verbalize: "Temporal and carotid arteries are palpable bilaterally."
HFN: Palpates: Maxillary and frontal sinuses for tenderness. - Answers :Palpate both
sinuses bilaterally (identifying location—maxillary or frontal during palpation) and ask
client if there is tenderness in either area. Verbalize: "No tenderness in maxillary or
frontal sinuses bilaterally."
HFN: Palpates: For symptoms of TMJ (pain, clicking, popping). - Answers :"I am going
to put my hands on both sides of your jaw and have you open and close your mouth. Do
you have any pain, clicking, or popping when you do this?" Verbalize: "Client denies
pain; no popping or clicking noted bilaterally."
HFN: Palpates: Cervical lymphatics (6 total)
Preauricular, posterior auricular, occipital, tonsillar, submandibular, submental. -
Answers :Palpate lymph nodes bilaterally, asking client to identify if there is any pain.
Identify location as you palpate.
Verbalize:"Lymph nodes are non-palpable and non-tender bilaterally."
HFN: Assesses and palpates: Trachea is mid-line - Answers :Facing patient, inspect
and gently palpate trachea. Verbalize: "Trachea is midline."
HFN: Assesses: Facial motor/sensation (CN V - TRIGEMINAL) jaw clench/wisp test. -
Answers :Must state the Cranial Nerve NUMBER and NAME for credit.
"I'm going to test your cranial nerves. First can you clinch your jaw? (client clinches
jaw). Now relax. Next, with your eyes closed, I'm going to touch you with this cotton ball
on the face. Please point to or tell me where you feel it on either side (right cheek, left
forehead, etc.)."
Have patient close their eyes and use the cotton swab/ball on forehead, cheek and
chinbilaterally."Thank you."Verbalize:"Cranial Nerve V, Trigeminal, is intact."
HFN: Assesses: Facial symmetry at least four assessments (CN VII - FACIAL).
Puffing checks, raising eyebrows/closing eyes tight, smile/frown. - Answers :"Next, we
are going to test your facial nerves. Can you puff both cheeks? Raise your eyebrows?
Close your eyes tight? Can you smile? And frown?"
Verbalize:"CN VII—Facial, is intact."
HFN: Assesses: Speech quality (CN XII - Hypoglossal) "light, tight, dynamite." -
Answers :Ask patient to say, "Light, Tight, Dynamite."
