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Nur 1020C Head to Toe Assessment Sheet
- Course
- NUR 1020C
- Institution
- Florida State College At Jacksonville
Head to Toe Assessment sheet for Nur 1020C. *Essential Study Material!!!
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Ansbacher/ Daniels 2021 Term 1Health Assessment Physical Exam Demonstration: 20 minutes
However, on the second attempt, the student must complete the entire physical examination
within the allotted 20 minutes and aim to achieve a maximum of 40 points overall (maximum
physical exam points=40; maximum documentation write-up points=7- under clinical
performance that week- documentation will be put into a sim chart.
Don Not
GENERAL SURVEY: Examiner introduces self to patient, performs hand hygiene e Done Pts
General Survey: appears stated age; alert & oriented to person, place, and time;
document all 4 parts of gen. survey
The patient looks to be her stated age and is
alert and oriented to person, place, and time.
Dressed appropriately and walking without assistance. 2
Perform Vital signs (include in documentation)
1
INTEGUMENTARY
1. Inspect hands for color, pigmentation; temperature; moisture; texture; turgor &
lesions
Skin is consistent w/ patient’s stated background/race.
Skin is warm/dry.
Skin turgor is prompt w/ good elasticity. No tenting.
No scars, lesions, or tattoos.
No pallor, no erythema, no cyanosis. 0.5
2. Inspect bilaterally fingernails and toenails for capillary refill (< 3 seconds)
Capillary refill is less than 3 seconds in upper and lower extremities bilaterally. 0.5
HEAD/NECK
1. Inspect face for bilateral symmetry: patient frown, close eyes tight, lift eyebrows,
show teeth. Have patient puff cheeks and watch as air escapes for bilateral symmetry
(CN VII: intact bilaterally?)
2. Inspect neck for symmetry; note if Trachea is midline.
Head is normocephalic.
CN 7 is intact by the facial expression test.
Facial features and neck are symmetrical-eyebrows, eyelids, the nose is
symmetrical (and proportional to the face), ears, palpebral fissures.
Trachea midline. 0.5
3. Assess - Eyes closed: light touch of cotton ball to forehead, cheeks, and chin (CN
V- Sensory: intact bilaterally?)
CN 5 sensory is intact by the cotton ball test. 0.5
4. Assess muscles of mastication as patient clenches teeth. Examiner tries to
separate jaw (CN V- Motor: intact bilaterally?)
CN 5 motor is intact by the jaw test.
TMJ is without popping. Patient denies any pain or tenderness. 0.5
5. Palpate carotid pulse (one at a time)- state strength;
6. Auscultate carotid pulse as pt. takes deep breath exhales and holds it; Listen for
bruits
Carotid pulse is 2+ bilaterally and
no bruits auscultated. 1
, 7. Assess active ROM of head and neck (head forward, head back; head side-to-side,
touch each shoulder);
Full active range of motion.
5/5 strength w/ and w/out resistance. 0.5
8. Assess active ROM of head and neck against resistance including shrug the
shoulders against resistance (CN XI: intact bilaterally?).
CN 11 is intact bilaterally by accessory spinal test.
0.5
EARS/NOSE/THROAT
1. Inspect external ears for bilateral symmetry: position; alignment; patency of
auditory meatus and
Ears are symmetrical and aligned.
Auditory meatus is patent bilaterally. 0.5
2. Palpate auricle, tragus, and mastoid process to assess for tenderness
Patient denies tenderness to the auricle, tragus, and mastoid process bilaterally.
3. Assess hearing with Whisper test (CN VIII intact bilaterally). Patient must repeat
whispered word
CN 8 is intact bilaterally by the whisper test. 1
3. Inspect external nose: midline(?), proportional to other facial features? Skin lesions?
Nares symmetry? Nares patent? Assess nares patency: Occlude one nares & sniff in
through other nares; Patient states smell (CN I intact bilaterally)
Nose is midline and proportional to other facial features.
Nares are symmetrical (look w/ pen light) and patent and there are no lesions.
No deviated septum.
CN 1 is intact bilaterally by the smell test. 1
4. Inspect the mouth: lips, Buccal mucosa, teeth & gums, tongue, hard & soft palate &
uvula.
Mouth is midline.
Lips are smooth and dry/ or cracked and dry.
Buccal mucosa is pink and moist.
Teeth & gums are in good condition.
Tongue is pink and moist.
Hard & soft palate are intact.
Uvula is pink and moist. 0.5
5. Inspect uvula and soft palate as patient says “Ahh”. Note if uvula and soft palate rise
in midline; then state test of CN IX and X would be to touch posterior pharynx and note
gag reflex (DO NOT PERFORM IN LAB). (CN IX & X intact bilaterally?)
6. Inspect tongue: Is it midline? Any tremors? Any deviation to one side? (CN XII)
Uvula and soft palate rise midline. CN 9 &10 are intact by the AHHH test.
Gag test- place tongue depressor at the posterior pharyngeal wall to elicit a gag
reflex.
Tongue is midline, no tremors or deviations.
CN 12 is intact by the tongue test. 1
EYES/VISION
1. Inspect external eye structures for bilateral symmetry: eyebrow, eyelids, palpebral 0.5
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