Head-To-Toe Assessment Exam Questions And Answers
Introduction
• Introduce yourself and inform the patient what you will be doing, head-to-toe
assessment, while washing your hands/ hand sanitize.
• Close the curtain or shut the door to the room for privacy.
• During your introduction observe the patient's mental status and level of
consciousness, mood, personal hygiene, skin color, posture/position, mobility, ability to
hear and speak.
Vital Signs
• Assess patient's vital signs: temperature, radial pulse, respirations, and blood
pressure.
• While you are taking their blood pressure, pulse etc., observe the patient's skin
surface characteristics (color, freckles, moles, etc.), temperature, and moisture.
• Observe patient's hands for symmetry. Observe nails for shape and contour,
cleanliness.
• Assess capillary refill and look for for clubbing of the fingers.
• Also take their height and weight.
Lower Extremity ROM (Range of Motion) and Romberg Test
Lower Extremities
•After you take their height and weight, tell them to walk toward you on their tip toes.
•Then have them walk the other way on their heels.
•Then tell them to walk heel to toe (in tandem) -- you should be beside them for every
exercise/activity you have them do.
•Have them twist side to side at the waist.
•Have them bend to one side and then to the other.
•Have them bend over and touch their toes while you inspect their spine with forefinger
, and middle finger spread apart to trace the spine. Make sure you stand at their side
when they do this and not behind them.
•Ask them to stand up and repeat the Romberg test with them standing at their side for
support. Ask them to close the eyes, hands extended out in front for 30 seconds .
•Then ask them to lift one knee then the other.
•Then extend one leg out then the other.
•Then extend one leg behind and then back then the other.
• Then, abduct and adduct both legs to the side.
• Have patient rotate their knee toward the outside and then toward the inside. Repeat
with the other leg.
• Then have the patient bring the heel of one foot up toward the shin of the other foot and
slide foot down. Do the same to the other side.
•Then have them do foot exercises-stick one foot out, flex, dorsiflex, rotation then same
with other foot.
•Then invert and evert feet.
Upper Extremity ROM
Upper Extremities
•Have them raise both hands above head then back down.
•Then raise both hands out to the side and back down.
•Extend arms behind and then back, do same with the other arm.
•Have them put arms out in front of them, like they are going to put up their dukes, but
then move the arm down and then back up again.
•Then have them put hands out. Spread fingers then together. Make a fist. Hands up
towards the ceiling then down towards the ground. Then in a circle/rotate.
•Then examine ROM of neck. Have them touch their chin to their chest, extend head
back, touch ear to shoulder and do same with opposite ear then instruct them to rotate
head the one way and then the other.
Then Inspect CN 2 (Optic)
• Now have the patient stand 20 feet away from the Snellen eye chart. Have them cover
Introduction
• Introduce yourself and inform the patient what you will be doing, head-to-toe
assessment, while washing your hands/ hand sanitize.
• Close the curtain or shut the door to the room for privacy.
• During your introduction observe the patient's mental status and level of
consciousness, mood, personal hygiene, skin color, posture/position, mobility, ability to
hear and speak.
Vital Signs
• Assess patient's vital signs: temperature, radial pulse, respirations, and blood
pressure.
• While you are taking their blood pressure, pulse etc., observe the patient's skin
surface characteristics (color, freckles, moles, etc.), temperature, and moisture.
• Observe patient's hands for symmetry. Observe nails for shape and contour,
cleanliness.
• Assess capillary refill and look for for clubbing of the fingers.
• Also take their height and weight.
Lower Extremity ROM (Range of Motion) and Romberg Test
Lower Extremities
•After you take their height and weight, tell them to walk toward you on their tip toes.
•Then have them walk the other way on their heels.
•Then tell them to walk heel to toe (in tandem) -- you should be beside them for every
exercise/activity you have them do.
•Have them twist side to side at the waist.
•Have them bend to one side and then to the other.
•Have them bend over and touch their toes while you inspect their spine with forefinger
, and middle finger spread apart to trace the spine. Make sure you stand at their side
when they do this and not behind them.
•Ask them to stand up and repeat the Romberg test with them standing at their side for
support. Ask them to close the eyes, hands extended out in front for 30 seconds .
•Then ask them to lift one knee then the other.
•Then extend one leg out then the other.
•Then extend one leg behind and then back then the other.
• Then, abduct and adduct both legs to the side.
• Have patient rotate their knee toward the outside and then toward the inside. Repeat
with the other leg.
• Then have the patient bring the heel of one foot up toward the shin of the other foot and
slide foot down. Do the same to the other side.
•Then have them do foot exercises-stick one foot out, flex, dorsiflex, rotation then same
with other foot.
•Then invert and evert feet.
Upper Extremity ROM
Upper Extremities
•Have them raise both hands above head then back down.
•Then raise both hands out to the side and back down.
•Extend arms behind and then back, do same with the other arm.
•Have them put arms out in front of them, like they are going to put up their dukes, but
then move the arm down and then back up again.
•Then have them put hands out. Spread fingers then together. Make a fist. Hands up
towards the ceiling then down towards the ground. Then in a circle/rotate.
•Then examine ROM of neck. Have them touch their chin to their chest, extend head
back, touch ear to shoulder and do same with opposite ear then instruct them to rotate
head the one way and then the other.
Then Inspect CN 2 (Optic)
• Now have the patient stand 20 feet away from the Snellen eye chart. Have them cover
