This document helps with the head-to-toe assessment of the class nur3270 (health assessment). I have written out things you need to assess during the evaluation. It includes hair & scalp, eyes, ears, nose, mouth, lungs, heart & pulses, abdominal, nail, skin, reflex, and range of motion.
If you ...
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Hello, My name is ____. I am going to be your nurse for today. Can you tell me your name and date of birth? And where are you?
I am going to be doing your head-to-toe assessment today. Before we start, do you have any pain or problems anywhere in your body?
If you have any questions while I am doing your assessment, feel free to ask.
I can inspect that the patient is relaxed, well groomed, dressed appropriately for the weather, the skin is intact, and speech is clear. She is also alert and oriented
times 3, and she has an upright posture.
Hair & Scalp
Do you itch your scalp? Have you noticed any changes in your hair?
What I will say How I want to do it Abnormal Finding
Skull I am going to start with your head. Your skull
is round with prominences in the frontal and
occipital areas posteriorly, which is
normocephalic.
Hair type I am going to look through your hair. - Thyroid disease alters the condition of the
Your hair is straight (curly), shiny, and smooth. hair, making it fine and brittle.
- Hair loss (alopecia) or thinning of the hair
No lesions, lumps, bruises, moles, or dandruff is usually related to genetic tendencies and
are present. Also, there are no lice or parasites endocrine disorders such as diabetes
present. mellitus, thyroiditis, and menopause.
- Poor nutrition causes stringy, dull, dry, and
thin hair.
- The oil of sebaceous glands lubricates the
hair, but excessively oily hair is associated
with androgen hormone stimulation.
- Dry, brittle hair occurs with aging and
excessive use of chemical agents
Hirsutism → Facial hair growth on the
upper lip, chin, and cheeks in females.
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Eyes
Do you wear glasses or contact lenses? When was your last eye exam?
What I will say How I want to do it Abnormal Finding
Inspect Your eyes are parallel, aligned with each other. Pull down on the lids and look at the sclera, Strabismus – cross-eyed, one eye deviated
Closing of your eyes is symmetrical and you conjunctiva, lash, and eyebrow. from the point of fixation; if constant, the
are blinking involuntarily. weak eye becomes “lazy.” If not
detected/corrected by 4-6 years, blindness
Now, I am going to pull down your eyelids, from disuse, known as amblyopia, may result.
ok?
The sclera is white and normal with no lesions. Bulging eye - hyperthyroidism
The conjunctiva is pink and vascular. Lash and coarse hair or no hair on the outside of the
eyebrow are distributed evenly, with no eyebrow = hypothyroidism
patches.
Palpate I am going to palpate the lacrimal gland; let
me know if you feel any pain.
No pain or tenderness was noted.
Snellen letter chart To check your optic nerve II, I would have you Optic nerve II (sensory)
Optic nerve II functions stand 20 feet away and read the smallest letter ➢ retrobulbar neuritis is an inflammatory
you can read. First w/o correction and then process of the optic nerve behind the
with it. Also, first with both eyes, then cover eye. Ex MS
each eye individually. For example, you get ➢ Papilledema 🡪 ↑ ICP r/t brain tumor
15/20 which means you can see at 15 feet or bleed
away what a normal person can see at 20 feet ➢ Optic atrophy 🡪 change in color of the
disc, ↓ visual acuity, ex. MS
away. And this is checking for your visual Explain Tumbling E or HOTV
acuity, optic nerve II sensory is intact.
PERRLA Now, I am going to shine a light on your eye Abnormal - Fixed pupils, strabismus, constant
from your left and right. Just look, stay ahead nystagmus, setting-sun sign, & slow lateral
for me. movements in one eye could indicate unilateral
Your pupil has direct constriction and blindness.
consensual response with the other eye.
And now stare at my penlight.
So your pupil is equal, round, reacted to light,
and accommodated Or PERRLA
Oculomotor nerve III function Now, follow my penlight, I am going to draw Oculomotor nerve III, trochlear nerve IV, and
Trochlear nerve IV function an H. abducens VI (motor)
Abducens nerve VI function The oculomotor nerve III, Trochlear nerve IV, ➢ nystagmus: constant involuntary eye
and Abducens never VI, which are motor movements
functions are intact. ➢ strabismus: Lack of muscular
coordination deviation of one or both
eyes
➢ diplopia: double vision
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Ears
Do you tend to have difficulty hearing?
What I will say How I want to do it Abnormal Finding
Inspect Your ears are symmetrical, equal to one
another.
Palpate I am going to palpate the pinna; let me know if
you feel any pain.
No pain or tenderness was noted.
Whisper test Can you cover one of your ears and repeat
what I whispered?
And now the same with the other ear.
Weber test Now I am going to do the weber test. Lmk if Lateralization → when one can’t hear in one
you can hear the sound in both of your ears. ear
Rinne test And now, I will perform the Rinne test, I am
going to put it on your mastoid process; let me Conduction deafness → bone conduction is
know if you stop hearing. And same let me longer than the air.
know when you stop hearing.
And the same with the other ears.
Your air conduction was twice as bone Vestibulocochlear nerve VIII (Sensory)
conduction. ➔ tinnitus & deafness are deficits
associated with a cochlear or
Vestibulocochlear VIII function Your vestibulocochlear nerve VIII sensory is auditory branch of the nerve
intact. ➔ Vertigo is associated with the
vestibular portion
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