CPE A #2 HEAD TO TOE ASSESMENT MANUSCRIPT IN ORDER
1. Introduce yourself
- “Good morning, my name is _______ I am going to be your student nurse today.”
2. Close curtains for privacy
3. Sanitize your hands and put on gloves.
4. Consent for head-to-toe assessment
- “I am going to be performing a head-to-toe assessment today, it should take around
20 minutes or so, is that okay?”
5. Raise bed to working level
- “I am going to raise your bed to my working level and lower your side rail, okay?”
Neurological assessment
Begin to ask the following questions:
1. “What is your name and DOB?”
2. “Do you know where you are?”
3. “Can you tell me todays date?”
4. “Can you tell me who the president is?”
Then state: “Patient is alert, awake and orientated to self-date and time x 4”
Head assessment.
1. Palpate head and hair distribution
- “I am going to be checking your head for any bumps, bruises or
abnormalities”
- “No abnormalities found.”
2. Check the hair distribution
- “Checking hair distribution and it is adequate, and patient seems to be well
groomed”
Eye assessment
1. Check conjunctiva and sclera.
- “Can you pull down your eyes for me so I can check your conjunctiva and
sclera?”
- “Conjunctiva is pink and moist, sclera is white.”
2. Utilize pen light to check pupil reflexes. Place your hand between both eyes,
start on the outside of the eye and shine the light and come in, repeat on the
other side.
- “I am going to shine this pen light into your eyes to check your pupil reflexes.”
3. Now check the 6 visual fields using the pen light and ask the patient to follow
the pen.
- “I am going to check the 6 visual fields for accommodation.”
- “Use your eyes to follow the pen light and don’t turn your head.”
- “Pupils are equal, round and reactive to light and accommodation” (PERRLA)
, Nostril assessment
1. Use pen light to check inside the nostrils.
- “Checking inside the nostrils for any deviations or abnormalities.”
- “No deviations or abnormalities noted.”
Ear assessment
1. Use pen light to check inside of the ears for cerumen or discharge.
- “I am going to check inside of the ears for any discharge or abnormalities.”
- “No discharge or abnormalities”
2. Check the back of the ears for any bruises, rashes, bumps.
- “I am going to check the back of your ears for any bumps bruises or rashes”
- “No abnormalities noted.”
Mouth Assessment
1. Use pen light to check inside the mouth
- “Checking inside the mouth for any lesions, missing teeth, noting any dentures, and
making sure uvula is midline”
- “Uvula is midline, mucous membrane is pink and moist, no lesions found.”
Neck assessment
1. Palpate the lymph nodes
- “Checking the lymph nodes for any swelling”
- “No swelling felt”
2. Inspect the trachea to ensure it is midline
- “Trachea is midline”
Pulses
1. Check carotid pulses ONE AT A TIME
- “Checking the carotid pulse one at a time, starting on the left, now the right”
- “Carotid pulses are equal on both sides plus two”
- “Checking the brachial, radial, femoral, popliteal, posterior tibial, and Doris pedis,
pulses are bilaterally equal plus 2”
Edema
1. When you are done checking the popliteal pulse and dorsalis check for edema by
palpating the legs
- “I'm going to palpate for edema, no edema noted.”
Hair distribution
1. After checking for edema, inspect the legs for hair distribution
- “Checking the legs for hair distribution, which is normal”
1. Introduce yourself
- “Good morning, my name is _______ I am going to be your student nurse today.”
2. Close curtains for privacy
3. Sanitize your hands and put on gloves.
4. Consent for head-to-toe assessment
- “I am going to be performing a head-to-toe assessment today, it should take around
20 minutes or so, is that okay?”
5. Raise bed to working level
- “I am going to raise your bed to my working level and lower your side rail, okay?”
Neurological assessment
Begin to ask the following questions:
1. “What is your name and DOB?”
2. “Do you know where you are?”
3. “Can you tell me todays date?”
4. “Can you tell me who the president is?”
Then state: “Patient is alert, awake and orientated to self-date and time x 4”
Head assessment.
1. Palpate head and hair distribution
- “I am going to be checking your head for any bumps, bruises or
abnormalities”
- “No abnormalities found.”
2. Check the hair distribution
- “Checking hair distribution and it is adequate, and patient seems to be well
groomed”
Eye assessment
1. Check conjunctiva and sclera.
- “Can you pull down your eyes for me so I can check your conjunctiva and
sclera?”
- “Conjunctiva is pink and moist, sclera is white.”
2. Utilize pen light to check pupil reflexes. Place your hand between both eyes,
start on the outside of the eye and shine the light and come in, repeat on the
other side.
- “I am going to shine this pen light into your eyes to check your pupil reflexes.”
3. Now check the 6 visual fields using the pen light and ask the patient to follow
the pen.
- “I am going to check the 6 visual fields for accommodation.”
- “Use your eyes to follow the pen light and don’t turn your head.”
- “Pupils are equal, round and reactive to light and accommodation” (PERRLA)
, Nostril assessment
1. Use pen light to check inside the nostrils.
- “Checking inside the nostrils for any deviations or abnormalities.”
- “No deviations or abnormalities noted.”
Ear assessment
1. Use pen light to check inside of the ears for cerumen or discharge.
- “I am going to check inside of the ears for any discharge or abnormalities.”
- “No discharge or abnormalities”
2. Check the back of the ears for any bruises, rashes, bumps.
- “I am going to check the back of your ears for any bumps bruises or rashes”
- “No abnormalities noted.”
Mouth Assessment
1. Use pen light to check inside the mouth
- “Checking inside the mouth for any lesions, missing teeth, noting any dentures, and
making sure uvula is midline”
- “Uvula is midline, mucous membrane is pink and moist, no lesions found.”
Neck assessment
1. Palpate the lymph nodes
- “Checking the lymph nodes for any swelling”
- “No swelling felt”
2. Inspect the trachea to ensure it is midline
- “Trachea is midline”
Pulses
1. Check carotid pulses ONE AT A TIME
- “Checking the carotid pulse one at a time, starting on the left, now the right”
- “Carotid pulses are equal on both sides plus two”
- “Checking the brachial, radial, femoral, popliteal, posterior tibial, and Doris pedis,
pulses are bilaterally equal plus 2”
Edema
1. When you are done checking the popliteal pulse and dorsalis check for edema by
palpating the legs
- “I'm going to palpate for edema, no edema noted.”
Hair distribution
1. After checking for edema, inspect the legs for hair distribution
- “Checking the legs for hair distribution, which is normal”
