Head to Toe Assessment Final Rubric Exam
Standard Precautions - ANSWER Infection control measures, including handwashing.
Client Identification - ANSWER Two identifiers to verify client's identity.
Privacy Provision - ANSWER Client privacy during assessment provided.
Comfortable Position - ANSWER Position client for comfort.
Allergy Inquiry - ANSWER Allergies and medication history questioned.
Vital Signs - ANSWER Temperature, pulse, respirations measured and verbalized.
Radial Pulse Measurement - ANSWER Count for 30 seconds and multiply by 2.
Respiration Measurement ANSWER Count for 30 seconds and multiply by 2.
Blood Pressure ANSWER Take and record client's blood pressure.
Oxygen Saturation ANSWER Check client's oxygen saturation levels.
Pain Assessment ANSWER OLDCART for assessment of pain.
Neurological Orientation ANSWER Assess client's orientation to person, place, time,
and situation.
, Skin Assessment ANSWER Check skin color, temperature, lesions, turgor.
Head Inspection ANSWER Assess scalp, hair, cranium, and face.
Probing Questions - Head- ANSWER Itching, loss of hair, headaches.
Facial Symmetry - ANSWER Note expression and symmetry during examination.
TMJ Palpation - ANSWER Palpate joint, noting click and pain.
Facial Sensation Test - ANSWER Test sensation using cotton ball on face.
Eye Inspection - ANSWER Note conjunctiva and sclera for abnormalities.
Probing Questions - Eyes- ANSWER Glasses worn, changes in vision, drainage.
Pupils - ANSWER Note size and PERRLA during exam.
Cardinal Fields Test - ANSWER Test eye movement and convergence.
Ear Inspection - ANSWER Inspect external ear and auditory canal.
Probing Questions - Ears - ANSWER Ask about use of hearing aids, pain in ears.
Nasal Inspection - ANSWER Inspect nares for septal deviation and drainage.
Standard Precautions - ANSWER Infection control measures, including handwashing.
Client Identification - ANSWER Two identifiers to verify client's identity.
Privacy Provision - ANSWER Client privacy during assessment provided.
Comfortable Position - ANSWER Position client for comfort.
Allergy Inquiry - ANSWER Allergies and medication history questioned.
Vital Signs - ANSWER Temperature, pulse, respirations measured and verbalized.
Radial Pulse Measurement - ANSWER Count for 30 seconds and multiply by 2.
Respiration Measurement ANSWER Count for 30 seconds and multiply by 2.
Blood Pressure ANSWER Take and record client's blood pressure.
Oxygen Saturation ANSWER Check client's oxygen saturation levels.
Pain Assessment ANSWER OLDCART for assessment of pain.
Neurological Orientation ANSWER Assess client's orientation to person, place, time,
and situation.
, Skin Assessment ANSWER Check skin color, temperature, lesions, turgor.
Head Inspection ANSWER Assess scalp, hair, cranium, and face.
Probing Questions - Head- ANSWER Itching, loss of hair, headaches.
Facial Symmetry - ANSWER Note expression and symmetry during examination.
TMJ Palpation - ANSWER Palpate joint, noting click and pain.
Facial Sensation Test - ANSWER Test sensation using cotton ball on face.
Eye Inspection - ANSWER Note conjunctiva and sclera for abnormalities.
Probing Questions - Eyes- ANSWER Glasses worn, changes in vision, drainage.
Pupils - ANSWER Note size and PERRLA during exam.
Cardinal Fields Test - ANSWER Test eye movement and convergence.
Ear Inspection - ANSWER Inspect external ear and auditory canal.
Probing Questions - Ears - ANSWER Ask about use of hearing aids, pain in ears.
Nasal Inspection - ANSWER Inspect nares for septal deviation and drainage.
