Clinical Skills for Nurses: Head-to-Toe Assessment,
Documentation & Checklist with questions and verified
answers
Head-to-Toe Assessment Checklist
Pre-Assessment Preparation
• [ ] Gather equipment (stethoscope, penlight, thermometer, BP
cuff, pulse oximeter)
• [ ] Perform hand hygiene
• [ ] Introduce self and explain procedure
• [ ] Ensure privacy and proper lighting
• [ ] Position client appropriately
HEAD AND NECK
Inspection:
• [ ] General appearance and level of consciousness
• [ ] Facial symmetry and expression
• [ ] Skin color, texture, and temperature
• [ ] Hair distribution and condition
• [ ] Eye symmetry, pupils (PERRLA), visual acuity
• [ ] Ear alignment, hearing acuity
• [ ] Nose symmetry, patency
• [ ] Mouth, teeth, gums, tongue, throat
, • [ ] Neck symmetry, range of motion
Palpation:
• [ ] Head for masses, tenderness
• [ ] Lymph nodes (preauricular, postauricular, occipital, tonsillar,
submandibular, submental, anterior cervical, posterior cervical,
supraclavicular)
• [ ] Thyroid gland
• [ ] Carotid pulses (one at a time)
• [ ] Temporal pulses
Auscultation:
• [ ] Carotid arteries for bruits
CHEST AND RESPIRATORY
Inspection:
• [ ] Chest shape, symmetry, movement
• [ ] Respiratory rate, rhythm, depth
• [ ] Use of accessory muscles
• [ ] Skin color and condition
Palpation:
• [ ] Chest expansion
• [ ] Tactile fremitus
• [ ] Point of maximal impulse (PMI)
Percussion:
, • [ ] Lung fields for resonance
Auscultation:
• [ ] Breath sounds (anterior, posterior, lateral)
• [ ] Heart sounds (aortic, pulmonic, tricuspid, mitral areas)
• [ ] Extra heart sounds, murmurs
ABDOMEN
Inspection:
• [ ] Abdominal contour, symmetry
• [ ] Skin condition, scars, distension
• [ ] Visible peristalsis or pulsations
• [ ] Umbilicus position
Auscultation (before palpation):
• [ ] Bowel sounds in all four quadrants
• [ ] Vascular sounds (aorta, renal arteries)
Percussion:
• [ ] General tympany
• [ ] Liver span
• [ ] Spleen dullness
• [ ] Bladder dullness
Palpation:
• [ ] Light palpation all quadrants
Documentation & Checklist with questions and verified
answers
Head-to-Toe Assessment Checklist
Pre-Assessment Preparation
• [ ] Gather equipment (stethoscope, penlight, thermometer, BP
cuff, pulse oximeter)
• [ ] Perform hand hygiene
• [ ] Introduce self and explain procedure
• [ ] Ensure privacy and proper lighting
• [ ] Position client appropriately
HEAD AND NECK
Inspection:
• [ ] General appearance and level of consciousness
• [ ] Facial symmetry and expression
• [ ] Skin color, texture, and temperature
• [ ] Hair distribution and condition
• [ ] Eye symmetry, pupils (PERRLA), visual acuity
• [ ] Ear alignment, hearing acuity
• [ ] Nose symmetry, patency
• [ ] Mouth, teeth, gums, tongue, throat
, • [ ] Neck symmetry, range of motion
Palpation:
• [ ] Head for masses, tenderness
• [ ] Lymph nodes (preauricular, postauricular, occipital, tonsillar,
submandibular, submental, anterior cervical, posterior cervical,
supraclavicular)
• [ ] Thyroid gland
• [ ] Carotid pulses (one at a time)
• [ ] Temporal pulses
Auscultation:
• [ ] Carotid arteries for bruits
CHEST AND RESPIRATORY
Inspection:
• [ ] Chest shape, symmetry, movement
• [ ] Respiratory rate, rhythm, depth
• [ ] Use of accessory muscles
• [ ] Skin color and condition
Palpation:
• [ ] Chest expansion
• [ ] Tactile fremitus
• [ ] Point of maximal impulse (PMI)
Percussion:
, • [ ] Lung fields for resonance
Auscultation:
• [ ] Breath sounds (anterior, posterior, lateral)
• [ ] Heart sounds (aortic, pulmonic, tricuspid, mitral areas)
• [ ] Extra heart sounds, murmurs
ABDOMEN
Inspection:
• [ ] Abdominal contour, symmetry
• [ ] Skin condition, scars, distension
• [ ] Visible peristalsis or pulsations
• [ ] Umbilicus position
Auscultation (before palpation):
• [ ] Bowel sounds in all four quadrants
• [ ] Vascular sounds (aorta, renal arteries)
Percussion:
• [ ] General tympany
• [ ] Liver span
• [ ] Spleen dullness
• [ ] Bladder dullness
Palpation:
• [ ] Light palpation all quadrants
