Felician College
School OF NURSING
NURS 306: HEALTH ASSESSMENT
Bedside Head to Toe Examination
Final Practicum – Faculty Version
Name________________________________ Date __________ Score______
Introduction
3 questions total about the systems
can have the patient walk into the room to start
Quick General Survey (8 points) Points
Appearance
Gait, posture & position comfortably erect (1 pt)
Look at gait when they walk in
Posture: they are erect, sitting down and comfortable
Dress, grooming & hygiene (1 pt)
Clothes are appropriate for age and season
She looks cleaned and like she takes care of herself
Nutritional status (1 pt)
How is your nutrional status? Are you eating health?
Patient appears to look healthy and doesn’t look malnourished.
Behavior
Level of consciousness (1 pt)
She looks awake and alert
Facial expression, mood, & affect (1 pt)
Appropiate facial expression for the room and enviorment, her mood
looks good and her affect is good
Cognition
Orientation to person, place & time (3 pts)
Ask her for her name, where is she, and the time and year
Who is the president?
Neurological and Musculoskeletal (6 points)
Pupils equal, round, react to light with accommodation (PERRLA)
(4 pts)
Say what PERRLA means
Shine light into eye to look at pupils shine light at an angle for both
pupils have her put her hand up to her nose to divide her eyes (started
out as a 3 and constricted to a 2 directly and 2 consensually) do this for
both eyes
Accommodation eyes constrict when she looks at an object far away
to close up
Muscle tone & strength upper extremities – bilateral hand grasps
(1 pt)
Have them stick their arms out; skin is warm and dry, hands are a little
moist (she must be nervous) have her squeeze your fingers as tight
as she can; have her push her arms against resistance
Muscle tone & strength lower extremities – bilateral plantar flexion
against resistance (1 pt)
push legs against resistance of my arms
Flex her feet and have her push them on the “gas pedal” force is
equal bilaterally
Respiratory (4 points)
Character of respiration (1 pt)
No abnormal signs of respiration; appears to sounds normal
They appear to be even and relaxed (both anteriorly and posteriorly
Auscultate anterior/ posterior breath sounds (3 pts)
Open her chest
Ask her to breathe in and out
Listen to all of the spots
Then have her turn and face me
Cardiac (8 points)
Auscultate apical heart rate for one full minute (3 pts)
Don’t have them lay flat (have them at an angle
Use the diaphragm not bell
Auscultate 5 cardiac landmarks (diaphragm and bell) (5 pts)
Start with angle of louie to right into the second intercostal space right
sternal border
Start with the bell of the stethoscope and then diaphram
Left sternal border
2nd Aortic
2nd ICS Pulmonic/ base
3rd IC Herbs point left sternal border
5th ICS tricuspid space left sternal border
5th ICS mid clavicular line (mitral/ apex)
Diaphram: hear high pitch sounds
Bell: hear low pitch sounds
Peripheral Vascular (9 points)
Palpate radial, dorsalis pedis & posterior tibial pulses bilaterally
(3 pts)
Radial Pulse
Dorsalis pedis: between the first and second toe but up a little bit
Posterior Tibial: Inside of the ankle (use 2 fingers and press in)
Bilaterally assess color, temperature, moisture, upper & lower
extremities (3 pts)
Color looks good and even on both sides
Moisture: sweating in hands bilaterally but probably due to exam but skin
is dry on the lower extremities ( can tell she moistures)
Tmperature feels good bilaterally for both upper and lower
Bilaterally check capillary refill upper & lower extremities (2 pts)
Use fingertips on each side: they get white and pink up with 1-2 seconds
Use toes on each side
Bilaterally check edema lower extremities (1 pt)
No signs of edema bilaterally
Gastrointestinal (8 points)
Describe contour, symmetry of abdomen (2 pts)
Looks flat
Cant see any signs of former surgery
Can see her breathing but cant see any pulsations
Symettry looks good bilaterally
***Test for skin eleasticity (can tell she isnt dehydrated)
Auscultate bowel sounds in all 4 quadrants (2 pts)
Start in lower right quadrant and go clockwise
She has bowel signs
Percuss abdomen in all 4 quadrants (2 pts)
Place middle finger and indirectly tap onto finger
Little tympany going on but that’s ok/ normal
Light palpation in all 4 quadrants (2 pts)
Start in lower right quadrant
Have her bend her knee to relax the abdominal muscles
Place hand and go into a circle
Any pain or tenderness?
Total points: 43
Passing score: 33 points or more
TIME LIMIT: 15 MINUTES
Faculty Signature_____________________________________