⭐ HEAD-TO-TOE CHECK-OFF
🔹INTRODUCTION & GENERAL
APPEARANCE (Rubric: Universal
Competencies + General Appearance)
“Hello, my name is Tia, and I am your student nurse today. I’m going to be performing a full
physical assessment. This will take about 30 minutes. If anything hurts or feels uncomfortable at
any point, please let me know.”
“I’m observing your general appearance now. You appear well-groomed, dressed appropriately,
and in no acute distress. Your posture is upright and relaxed.”
🔹 MENTAL STATUS & ORIENTATION
(Rubric: Neuro/Cognitive)
“Before I begin, I want to check your mental status. Can you tell me your full name and date of
birth? Can you tell me where you are right now? What is today’s date? And who is the current
president?”
“Great, you are alert and oriented to person, place, time, and situation.”
, 🔹SIMPLE COMMANDS + MOTOR
RESPONSE
“Now I’m going to assess your motor response. Can you squeeze my hands? Good. Now press
down like a gas pedal… and pull your feet up toward your head. Perfect. Strength is strong and
equal bilaterally.”
🔹SENSATION (Rubric: Sensation face,
upper, lower extremities bilaterally)
“Next I’m going to test sensation. I’ll touch you with something soft and something sharp. Please
tell me which you feel.”
“Great — sensation is intact on the face, upper extremities, and lower extremities bilaterally.”
🔹COORDINATION & GAIT
“Now I’m going to assess your coordination and gait. Please take a few steps forward for me.”
“Your gait is coordinated, steady, and balanced.”
🔹CRANIAL NERVES (Rubric: Must assess
ALL)
🔹INTRODUCTION & GENERAL
APPEARANCE (Rubric: Universal
Competencies + General Appearance)
“Hello, my name is Tia, and I am your student nurse today. I’m going to be performing a full
physical assessment. This will take about 30 minutes. If anything hurts or feels uncomfortable at
any point, please let me know.”
“I’m observing your general appearance now. You appear well-groomed, dressed appropriately,
and in no acute distress. Your posture is upright and relaxed.”
🔹 MENTAL STATUS & ORIENTATION
(Rubric: Neuro/Cognitive)
“Before I begin, I want to check your mental status. Can you tell me your full name and date of
birth? Can you tell me where you are right now? What is today’s date? And who is the current
president?”
“Great, you are alert and oriented to person, place, time, and situation.”
, 🔹SIMPLE COMMANDS + MOTOR
RESPONSE
“Now I’m going to assess your motor response. Can you squeeze my hands? Good. Now press
down like a gas pedal… and pull your feet up toward your head. Perfect. Strength is strong and
equal bilaterally.”
🔹SENSATION (Rubric: Sensation face,
upper, lower extremities bilaterally)
“Next I’m going to test sensation. I’ll touch you with something soft and something sharp. Please
tell me which you feel.”
“Great — sensation is intact on the face, upper extremities, and lower extremities bilaterally.”
🔹COORDINATION & GAIT
“Now I’m going to assess your coordination and gait. Please take a few steps forward for me.”
“Your gait is coordinated, steady, and balanced.”
🔹CRANIAL NERVES (Rubric: Must assess
ALL)
