Head to Toe Assessment Steps
Skill 1 - Greet client and explain purpose of exam; wash or purell before entering patient room.
Introduce yourself as a student Nurse. Ask patient to remember three words: APPLE, BOAT,
CHEESE.
Skill 2 - General survey- appearance, facial expression, speech, mental state; Speech is clear,
slurred, rapid, slow, no evidence of pain, face symmetrical. Alert and oriented to person, place
and time.
Skill 3 - Level of consciousness Alert and oriented x3
Skill 4 - Have client close eyes; Assess for asymmetry of lids may indicate CN III damager or from
a stroke.
Skill 5 - Have client raise eyebrows; Facial nerve VII
Skill 6 - Have client smile; Facial nerve VII
Skill 7 - Have client stick out tongue; CN XII- hypoglossal nerve
Skill 8 - Have client puff cheeks- CN VII- facial nerve
Skill 9 - Discriminatory sensations- soft and sharp object to face; CN V-
, Skill 10 - Test EOMs; test 6 cardinal fields of gaze (test cranial nerves III, IV, and VI- oculomotor,
trochlear, and abducens nerves. Change in ICP may affect EOMs and papillary reaction.
Skill 11 - Inspect conjunctiva for color by pulling lid down; abnormal findings would be pallor,
dryness, edema
Skill 12 - Test pupillary response with penlight- direct, describe what is see; When you shine a
light in the right eye, the right pupil reaction is direct; the left eye is consensual. Repeat the test
with the left eye.
Skill 13 - Test pupillary response with penlight- consensual, describe what is seen; Sluggish or
fixed pupils may result from CN II damage or brain injury. Absence of consensual response may
result from nerve compression or anoxia.
Skill 14 - Test pupil accommodation- explain; Have the patient look straight ahead and focus on
an object 30cm (12in) from his face. Slowly bring the object in toward the patient's eye. Note
the pupil size and location.
Skill 15 - Inspect external structure of ear; Ears should be 4-10 cm in size. Color of ears should
be same as skin color. Assess for any drainage, odor or pain when assessing ears.
Skill 16 - Examine oral mucosa; Assess for lesions, edema, plaque, ulcers.
Skill 17 - Inspect palate; Assess for cleft palate, pink in color. Uvula is midline. Tonsils are pink
with out lesions or exudates.
Skill 18 - Have client say "ah"- what do you observe for?; Uvula should rise when patient says
ah- CN IX
Skill 1 - Greet client and explain purpose of exam; wash or purell before entering patient room.
Introduce yourself as a student Nurse. Ask patient to remember three words: APPLE, BOAT,
CHEESE.
Skill 2 - General survey- appearance, facial expression, speech, mental state; Speech is clear,
slurred, rapid, slow, no evidence of pain, face symmetrical. Alert and oriented to person, place
and time.
Skill 3 - Level of consciousness Alert and oriented x3
Skill 4 - Have client close eyes; Assess for asymmetry of lids may indicate CN III damager or from
a stroke.
Skill 5 - Have client raise eyebrows; Facial nerve VII
Skill 6 - Have client smile; Facial nerve VII
Skill 7 - Have client stick out tongue; CN XII- hypoglossal nerve
Skill 8 - Have client puff cheeks- CN VII- facial nerve
Skill 9 - Discriminatory sensations- soft and sharp object to face; CN V-
, Skill 10 - Test EOMs; test 6 cardinal fields of gaze (test cranial nerves III, IV, and VI- oculomotor,
trochlear, and abducens nerves. Change in ICP may affect EOMs and papillary reaction.
Skill 11 - Inspect conjunctiva for color by pulling lid down; abnormal findings would be pallor,
dryness, edema
Skill 12 - Test pupillary response with penlight- direct, describe what is see; When you shine a
light in the right eye, the right pupil reaction is direct; the left eye is consensual. Repeat the test
with the left eye.
Skill 13 - Test pupillary response with penlight- consensual, describe what is seen; Sluggish or
fixed pupils may result from CN II damage or brain injury. Absence of consensual response may
result from nerve compression or anoxia.
Skill 14 - Test pupil accommodation- explain; Have the patient look straight ahead and focus on
an object 30cm (12in) from his face. Slowly bring the object in toward the patient's eye. Note
the pupil size and location.
Skill 15 - Inspect external structure of ear; Ears should be 4-10 cm in size. Color of ears should
be same as skin color. Assess for any drainage, odor or pain when assessing ears.
Skill 16 - Examine oral mucosa; Assess for lesions, edema, plaque, ulcers.
Skill 17 - Inspect palate; Assess for cleft palate, pink in color. Uvula is midline. Tonsils are pink
with out lesions or exudates.
Skill 18 - Have client say "ah"- what do you observe for?; Uvula should rise when patient says
ah- CN IX
