Head to Toe Assessment Script for Nursing NUR 101_ Practical Guide

Head to Toe Assessment Script

Introduce yourself
Explain procedure
Name and DOB, allergies
Pull curtains
Hand sanitizer and apply gloves
Assess pain (scale of 0 – 10)

Mental Status:
Alert and Oriented:
- Can you tell me your name? (Person)
- Can you tell me where you are? (Place)
- Can you tell me what year it is? (Time)
- Can you tell me who the president is? (Event)
“Patient is alert and oriented times 4, appears to be coherent, dressed and acting appropriately
appears to have proper responses to commands”

Head:
Top of Head
Palpate the skull for deformities
Make notes of hair patterns “hair is evenly distributed and intact”
Palpate facial structures “Facial features are symmetric”
Assess sinuses – ask if any tenderness or pain
Feel skin with back of hand and make note of any skin abnormalities “there are no
lesions, lumps, or bruising. Skin is warm, dry, and intact”
Eyes
Assess eyebrows, eyelash, and eyelids are symmetrical and have normal distribution, and
inspect eyes “no drainage present, conjunctiva is pink and moist, irises are brown, pupils
are black, sclera is white, pupils are a size 4”
assess cranial nerve III, IV, VI
follow cardinal field of gaze
PERRLA
cranial nerve II
read my badge
Hirshberg test (corneal light reflex)
shine the light at the nose and look for equal reflection on both eyes
“is present and symmetric”
Nose
Use penlight to shine up nose to assess for septum deviation “no septum deviation”
Assess cranial nerve I
Close your eyes and smell alcohol prep pad while occluding one side at a time
Palpated cartilage to assess for abnormalities
Ears:
“Ears look symmetrical, no swelling or tenderness present, behind the ears appears to be
intact, not dry, no drainage”

, Assess cranial nerve VIII
Whisper test: cover opposite ear while whispering in one ear. Say three words and
have them repeat it back
Mouth
Assessing mucosa: “pink, moist, no lesions or sores present, teeth and gums don’t appear
abnormal”
Assess cranial nerve VII
Smile, puff cheeks, squeeze eyes shut, go from smiling to frowning
Assess cranial nerve IX
Say “ah”
Assess cranial nerve X
Speech and swallowing
Assess cranial nerve XII
Stick out tongue and move it up and down, left and right
Cranial nerve V
Sharp/dull test throughout the face
Have them clench their jaw and palpate temporomandibular joint (ROM)
Cranial nerve XI
Shrug shoulders, turn head against hand resistance
“all cranial nerves are intact, full ROM in temporomandibular joint”

Throat:
Palpate for abnormalities
Assess trachea is midline, “Trachea is midline, symmetrical, Thyroid is not palpable”
Palpate carotid pulses (1 at a time) “carotid pulses are 2+”
Assess Juglar venous distention with 30-degree HOB elevation
“JVD not present”
Assess lymphatic ducts (See pages below) “no inflammation in lymph nodes”
ROM of cervical spine
Flexion – touch chin to chest
Extension – bend head back
Right and right lateral bending – bend beck to the right
Rotation – turn head left and right toward shoulder
“has full ROM of cervical spine”