10/16/24, 12:17 Student - Head to toe Health Assessment Check
PM off list
Head to Toe Health Assessment Check off List
Introduction – Inform patient who you are and what you will be doing and approx how long it
will take. Provide privacy.
Wash Hands – gloves
General Survey
Begin assessment with the initial encounter of patient and continue it throughout the encounter.
Note patient’s mental status. Note orientation – their name, the day or date, where they are and why
they are there. Are they agitated or confused? Eye contact (consider cultural variations), appearance,
hygiene.
Levels of consciousness – alert, lethargic, obtunded, stuporous, and comatose.
Observe for non-verbal cues, (general) mobility and ROM. Is patient walking around, can they push
themselves up in the bed.
ASK about:
CC (Chief Complaint)
(one little phrase). Major complaint that patient presents with.
HPI (History of Present Illness) Signs and symptoms around the chief complaint.
PMH (Past Medical History) Is past history contributory or not?
Vital Signs: (5) – Know the normal values! But what is normal for the patient?
Temperature – No axillary values
Blood Pressure – 120/80 – (Make sure you have the right sized cuff for the patient)
Respirations – 10-20 breaths per min
Pulse Rate – 60-100 beats per min
Pain – Offer Scale – 0-10. Zero being no pain and 10 being the worst pain you could imagine
If patient has pain, note location, onset & duration, quality, intensity, alleviating &
aggravating factors and pattern. (Is it stationary or does it radiate – to where?)
Assessment of Neurological Status
Ask patient to state their name, date, purpose for visit and location.
Ask patient to smile, frown, raise eyebrows and show their teeth to you.
Assessment of Head and Neck
Inspect – Head for shape and symmetry and lesions or contusions, and hair for lice. Assess for
mobility of neck, distended veins (pt should be sitting at a 45 degree angle) in the neck, symmetrical
placement of eyes, ears, nose and mouth. Facial skin for lesions, moles, birthmarks, etc.
Inspect eyes for movement and focus
Check with penlight for (PERRLA) pupils equal in size, round, reactive to light and
accommodation. Noting briskness of reaction. Note eye movement and ability to focus. Note color of sclera
and conjunctiva
Check behind ears for lesions. Noting any drainage from the eyes, ears or nose or any drooling from
the mouth. Is this a normal variant for age of patient?
Palpate scalp and neck – looking for lesions, tenderness, swollen lymph nodes along back of neck
and along chin line and down either side of neck.
Check nose with penlight noting any s/o trauma or nasal congestion
Ask patient to open their mouth and stick out their tongue, then wiggle it side to side. Can they
smile? Is there debris in their mouth? Look under tongue and note hydration status of mucosa. Note any
odor. What knowledge can you gain from this exam?
Does patient wear dentures? Are they causing him/her any problems? Does he/she need a container to store
them in?
Palpate throat. Ask patient to swallow while feeling for thyroid. Auscultate carotid arteries. One side
at a time!
about:bl 1
PM off list
Head to Toe Health Assessment Check off List
Introduction – Inform patient who you are and what you will be doing and approx how long it
will take. Provide privacy.
Wash Hands – gloves
General Survey
Begin assessment with the initial encounter of patient and continue it throughout the encounter.
Note patient’s mental status. Note orientation – their name, the day or date, where they are and why
they are there. Are they agitated or confused? Eye contact (consider cultural variations), appearance,
hygiene.
Levels of consciousness – alert, lethargic, obtunded, stuporous, and comatose.
Observe for non-verbal cues, (general) mobility and ROM. Is patient walking around, can they push
themselves up in the bed.
ASK about:
CC (Chief Complaint)
(one little phrase). Major complaint that patient presents with.
HPI (History of Present Illness) Signs and symptoms around the chief complaint.
PMH (Past Medical History) Is past history contributory or not?
Vital Signs: (5) – Know the normal values! But what is normal for the patient?
Temperature – No axillary values
Blood Pressure – 120/80 – (Make sure you have the right sized cuff for the patient)
Respirations – 10-20 breaths per min
Pulse Rate – 60-100 beats per min
Pain – Offer Scale – 0-10. Zero being no pain and 10 being the worst pain you could imagine
If patient has pain, note location, onset & duration, quality, intensity, alleviating &
aggravating factors and pattern. (Is it stationary or does it radiate – to where?)
Assessment of Neurological Status
Ask patient to state their name, date, purpose for visit and location.
Ask patient to smile, frown, raise eyebrows and show their teeth to you.
Assessment of Head and Neck
Inspect – Head for shape and symmetry and lesions or contusions, and hair for lice. Assess for
mobility of neck, distended veins (pt should be sitting at a 45 degree angle) in the neck, symmetrical
placement of eyes, ears, nose and mouth. Facial skin for lesions, moles, birthmarks, etc.
Inspect eyes for movement and focus
Check with penlight for (PERRLA) pupils equal in size, round, reactive to light and
accommodation. Noting briskness of reaction. Note eye movement and ability to focus. Note color of sclera
and conjunctiva
Check behind ears for lesions. Noting any drainage from the eyes, ears or nose or any drooling from
the mouth. Is this a normal variant for age of patient?
Palpate scalp and neck – looking for lesions, tenderness, swollen lymph nodes along back of neck
and along chin line and down either side of neck.
Check nose with penlight noting any s/o trauma or nasal congestion
Ask patient to open their mouth and stick out their tongue, then wiggle it side to side. Can they
smile? Is there debris in their mouth? Look under tongue and note hydration status of mucosa. Note any
odor. What knowledge can you gain from this exam?
Does patient wear dentures? Are they causing him/her any problems? Does he/she need a container to store
them in?
Palpate throat. Ask patient to swallow while feeling for thyroid. Auscultate carotid arteries. One side
at a time!
about:bl 1
