Introduction* 'Hello, my name is Sarah, and I'm going to be

your nurse today, and I need to perform a head-

"This is Sarah with [Link], and
to-toe assessment. Is that okay with you?'
in this video, I'm going to be performing a
nursing head-to-toe assessment. This video will Okay. Then proceed and look at their armband.
be similar to what you have performed in So while you're doing this, this is going to help
nursing school whenever you're doing your you make sure you have the right patient, and
clinical check-off. Now, whenever you actually you're going to be testing them to see if they
start working as a nurse, you'll be able to tailor know who they are, their date of birth, and ask
this head-to-toe assessment to focus on the them some other questions to assess their
patient's needs, and you'll get a lot faster at neurostatus."*
this. So what I want to do is I want to cover
Patient Identity Check (Neuro Assessment)*
literally how to assess from the hair on the head
all the way down to the toes. So let's get "Say your first and last name for me."
started."
*(Patient: "First name is Ben, last name is
Dover.")*
General Approach* "Okay, and your date of birth?"
"Now, when you're doing your head-to-toe *(Patient: "8/28/82.")*
assessment, you follow that sequence of how
you assess each system. So you start out "Okay, and do you want me to call you Ben or
whenever you're looking at a system, you're Mr. Dover?"
going to inspect it, then palpate, percuss, and *(Patient: "What do you mean?")*
then auscultate. Except you're going to change
it up a little bit whenever you're going over the "Okay, so Ben, can you tell me where you're
abdomen. You're going to inspect, auscultate, at?"
percuss, and then palpate. And the reason that *(Patient: "I'm at the hospital.")*
you're going to auscultate second instead of last
is because whenever you perform palpation and "Okay, and can you tell me what we're doing
percussion, if you did that before, it could alter here today?"
the bowel sounds. So we want to go ahead and
*(Patient: "A head-to-toe assessment.")*
just auscultate, get a baseline of what we can
hear, and then we will percuss and palpate." "Okay, and who's the President of the United
States?"

*(Patient: "Donald Trump.")*

Initial Patient Interaction*
"Okay, so he answered all those correctly, and
*"So first, what you want to do is you want to
he's alert and oriented times four. He knew who
perform hand hygiene and provide privacy to
he was, he was able to tell me his name, his
the patient. Then introduce yourself to the
date of birth, where he was, what we're doing,
patient and explain what you're going to be
and current events. So we can chart alert and
doing. So:
oriented times four."
Vital Signs* Is there a delay in his responses, or does he
respond appropriately and at an appropriate
*"Then you want to collect vital signs such as
time?
the patient’s heart rate, blood pressure,
temperature, oxygen saturation, respiratory Do you notice any outward abnormalities like
rate, and the patient’s pain rating. amputations, masses, or lesions?

-So Ben, are you having any pain on a scale of Is his skin sweaty, cold, and clammy?
zero to ten, with zero being no pain at all and
Do you notice any cyanosis right off the bat?
ten being the worst pain you’ve ever had?"*
Is his hygiene good?
*(Patient: "No pain, zero.")*
Is his posture good?
"Okay. And I have a video on how to assess
those vital signs in depth if you want to watch Do you notice any abnormal smells?"*
that video, and a card should be popping up so
you can access that video."
Now, what we're going to do is we're going to
start with the head and move our way down to
Observations While Assessing* the toes. So we are first going to inspect the
head, and we are looking at the skin color—it's
*"Then after that, what you want to do is you
nice and pink.
can collect their height and their weight and
look at their BMI, their Body Mass Index.  We're also going to make sure that the
Remember, if it's 18.5 or less, that's head is the same size as how it should
underweight. If it's greater than 30, that is be for the body, and it is.
obese.  We're looking for any abnormal
movements or twitching of the face
Now, while you've been doing all that—asking
that he can't control, that are
them these questions, doing their vital signs—
involuntary. We don't see anything.
you’re also, before you’ve even really started
 We're making sure that the face is
the system assessments, already collecting
symmetrical. There's no drooping on
information.
one side. Like in this picture, there's
drooping on one side of the face, and
this can be seen in Bell's palsy or in
For instance:
stroke.
How is that patient responding to you?  And we're also just looking at the eyes
and the ears—are they at the same
What’s their emotional status? Are they calm, level?
agitated, or drowsy?

Does he look his stated age?

And while we're here, we're going to go ahead
Does his skin color match his ethnicity? and look at the facial expressions and test
Does he understand my questions, or does he cranial nerve 7, which is the facial nerve.
seem like he can’t hear them very well? So: Can you close your eyes tightly for me? And
open them up?
Okay, now smile for me.  Next, what we're going to do is we're
going to find the temporal artery, and
Frown.
we're going to palpate them bilaterally.
Puff out your cheeks.  They are both found right here, and his
are about a *2+*.
Okay, and he did that with ease, so that cranial  Then while we're right there, we're
nerve is intact."* going to go ahead and test cranial nerve
Palpating the Head & Hair* 5, which is the trigeminal nerve
 And this nerve is responsible for many
*"Next, what we're going to do is we're going to things, like mastication.
palpate the head—the cranium.
So what I'm gonna have you do, Ben, is:
-We're going to check for any masses,
indentations, look for skin breakdown, any  Clench your teeth, like bite down for
infestations. And for this part, I like to wear me.
gloves.  And I'm going to feel the masseter
muscle, which is right there—it should
So let's look at the hair. be a nice firm ball.
 What we're doing is we're feeling for Then feel the temporal muscle.
any masses, indentations. Also, with
this, we're looking for any skin  Now, what I'm going to do to also test
breakdown. that nerve is have him try to open his
 And if your patient is immobile, you mouth against resistance.
really want to check the back of the So try to do that for me.
head back here because they're laying
on it a lot, and there can be -Okay, and he can do that."*
breakdown back there.
Temporomandibular Joint (TMJ) & Sinus
 Also, while you're doing that, look
Palpation*
inside the hair. Make sure there is no
infestations like lice and there's no  "Now while we're here, we're going to
abrupt rounding areas of baldness, go ahead and feel the
which could represent alopecia. **temporomandibular joint (TMJ)*.
 Then after that, since this patient has a
And we're going to feel right here.
beard, you want to check the beard as
well—any lesions, any infestations, or  I'm going to have you open and close
anything like that. your mouth.
 And just look around.
And I'm feeling for any grating or clicking
Then once you're done with that, what you sensations, and I feel none.
want to do is you'll doff your gloves and
perform hand hygiene."*  Then we're going to palpate the sinuses.
 I'm going to put pressure on these two
Temporal Artery & Cranial Nerve 5 (Trigeminal sinuses right here.
Nerve)*
You tell me if you feel any pain.
Okay, so the *maxillary and the frontal**—no Next, what we're going to do is *assess some
pain." cranial nerves*:

Eye Inspection & Cranial Nerve Testing (III, IV, - *Cranial nerve III (Oculomotor)*
VI)*
- *Cranial nerve IV (Trochlear)*
*"Next, we're moving down to the eyes, and
- *Cranial nerve VI (Abducens)*
we're going to inspect the eyes first.
 We're gonna do several tests to check
We're looking at several things:
their function.
- The *eyelid*
The first one—what we're gonna do—is look for
- The *sclera* (the white of the eyes) any *involuntary shaking of the eye called
nystagmus*.
- The *iris*
How we're going to do that is:
- The *pupil*
- We're going to take our *penlight*
- The *conjunctiva*
- Hold it *12 to 14 inches* away from the
You shouldn't see any swelling of the eyelids.
patient’s nose And then:
 You should see that the sclera is
 *"I want you to keep your head still—
**white and shiny**—it shouldn't be
don’t move your head—just use your
yellow like in jaundice.
eyes to watch where I move the
 And the conjunctiva—when you pull
penlight."*
down the lower lid, have the patient
 As you're doing this, perform it in the
look up—it should be *nice and pink*.
*six cardinal fields of gaze*, moving it
It shouldn't be red. You shouldn't see any in different directions.
drainage or anything like that.
You're looking for any *involuntary shaking of
And look at the eyes—how do they set in the the eyes*."*
eye socket? Are they equal?

For instance, is there any **strabismus**—is

General Preparation:*
there a cross-eye where one eye turns in more,
turns out, or up or down? Perform hand hygiene and provide privacy to
the patient.
And these eyes are normal. There's no
strabismus. Introduce yourself to the patient and explain
the procedure.
 Next, you want to look at *anisocoria*,
where you have one pupil that would Verify patient identity using armbands.
be smaller than the other pupil.
Assess the patient’s level of consciousness and
-Are they equal in size?
orientation:
-Normal pupils should be *3 to 5 mm* in their
measurement, and here, his are about a *3*,
and they are equal. - "Say your first and last name."
 - "What is your date of birth?" Palpate the temporal artery bilaterally (assess
pulse strength, 2+ normal).
- "Where are you right now?"
Test Cranial Nerve V (Trigeminal Nerve):
- "What are we doing today?"
- "Clench your teeth."
- "Who is the president of the United States?"
- "Bite down while I feel the masseter and
Collect vital signs:
temporalis muscles."
- Heart rate, blood pressure, temperature,
- "Try to open your mouth against resistance."
oxygen saturation, respiratory rate.
Palpate the TMJ joint while the patient opens
- Assess pain level: "On a scale of 0 to 10, do
and closes the mouth (check for clicking or
you have any pain?"
grinding).
Collect height, weight, and BMI.
Palpate the sinuses (frontal and maxillary) and
Observe general appearance: check for tenderness.

- Emotional status, hygiene, skin color, posture. *Eyes:*

- Any abnormalities (amputation, masses, Inspect eyelids, sclera (white, shiny),

lesions, cyanosis, abnormal odors). conjunctiva (pink, no drainage).

Check for strabismus (crossed eyes) or

anisocoria (unequal pupils).
*Head and Face:*
Assess pupil size (3-5 mm, equal in size).
Inspect the head for:
Test Cranial Nerves III, IV, and VI:
- Skin color, symmetry, involuntary
movements. - Six cardinal fields of gaze (check for
nystagmus/involuntary shaking).
- Facial drooping (Bell’s palsy, stroke).
- Pupil light reaction: Shine penlight from the
- Level of eyes and ears. side and observe constriction.
Test Cranial Nerve VII (Facial Nerve): - Accommodation: Have the patient focus on a
distant object, then move penlight toward the
nose and observe pupil constriction and eye
- "Close your eyes tightly." convergence.
- "Smile, frown, and puff out your cheeks." - Document as PERRLA (Pupils Equal, Round,
Palpate the cranium: Reactive to Light and Accommodation)

- Check for masses, indentations, skin *Ears:*

breakdown, infestations (wear gloves). Inspect for abnormalities, redness, drainage.
- Inspect hair for lice or alopecia. Palpate the outer ear and mastoid process for
- Inspect beard for lesions or infestations. tenderness.
Use an otoscope to inspect the tympanic Check for jugular vein distension (JVD) at 45-
membrane (should be pearly gray and degree angle.
translucent, cone of light at 5 o’clock in right
Palpate the trachea, lymph nodes, and carotid
ear, 7 o’clock in left ear).
arteries (one side at a time, 2+ normal
Test Cranial Nerve VIII (Vestibulocochlear strength).
Nerve):
Auscultate carotid arteries with the bell of the
- Whisper test: Cover one ear, whisper two stethoscope for bruits (abnormal swooshing
words, and have the patient repeat them. sound).

*Nose:* *Upper Extremities:*

Inspect for alignment, nasal septum deviation. Inspect for lesions, swelling, IV sites.

Check for drainage or polyps. Palpate radial and brachial pulses (2+ normal).

Assess patency by occluding one nostril at a Check capillary refill (<2 seconds).
time and having the patient breathe out.
Assess skin turgor for dehydration.
Test Cranial Nerve I (Olfactory Nerve):
Test range of motion and joint condition.
- "Close your eyes, inhale this scent, and tell
Test muscle strength:
me what it is."
- "Squeeze my fingers."
*Mouth and Throat:*
- "Push up against my hands."
Inspect lips (pink, no sores or cracking).
Check for arm drift (hold arms out with eyes
Test Cranial Nerve XII (Hypoglossal Nerve):
closed for 10 seconds).
- "Stick out your tongue and move it side to
*Chest:*
side."
Inspect respiratory effort and accessory muscle
Inspect oral mucosa, tongue, gums, and teeth
use.
for lesions, moisture, and signs of anemia.
Auscultate heart sounds at five locations:
Inspect the uvula and test Cranial Nerve IX
(Glossopharyngeal) and X (Vagus Nerve): - Aortic (2nd right intercostal space)
- "Say ‘ahh’ and check for uvula rise." - Pulmonic (2nd left intercostal space)
- Test gag reflex. - Erb’s point (3rd left intercostal space)
*Neck:* - Tricuspid (4th left intercostal space)
Inspect for lesions, lumps, and trachea midline. - Mitral (5th left intercostal space, mid-
clavicular line)
Test Cranial Nerve XI (Accessory Nerve):
Check apical pulse (listen for one full minute).
- "Move your head side to side, up and down."

- "Shrug your shoulders against resistance."

Auscultate lung sounds anteriorly, laterally, and Perform hand hygiene.
posteriorly (assess for crackles, wheezes,
Document findings.
stridor, or friction rubs).

*Abdomen:*
Head-to-Toe Nursing Assessment Script
Inspect for contour (scaphoid, flat, rounded,
protuberant), pulsations, and hernias. *General Preparation:*
Listen to bowel sounds in all four quadrants (5-  Perform hand hygiene and provide
30 per minute; listen for five minutes if absent). privacy to the patient.
Auscultate vascular sounds (aorta, renal, iliac  Introduce yourself to the patient and
arteries) with the bell. explain the procedure.
Palpate lightly, then deeply for tenderness,  Verify patient identity using armbands.
rigidity, and masses.
 Assess the patient’s level of
*Lower Extremities:* consciousness and orientation:
Inspect color, hair growth (sign of circulation), - "Say your first and last name." - "What is your
swelling, and ulcers. date of birth?" - "Where are you right now?" -
"What are we doing today?" - "Who is the
Palpate popliteal, posterior tibial, and dorsalis
president of the United States?"
pedis pulses (2+ normal).
 Collect vital signs:
Check capillary refill (<2 seconds).
- Heart rate, blood pressure, temperature,
Assess for edema (press tibia for pitting edema).
oxygen saturation, respiratory rate. - Assess
Test muscle strength: pain level: "On a scale of 0 to 10, do you have
any pain?"
- "Push against my hands."
 Collect height, weight, and BMI.
- "Raise legs against resistance."
 Observe general appearance:
Test Babinski reflex (normal: toes curl inwards).
- Emotional status, hygiene, skin color, posture.
*Back and Skin Assessment:*
- Any abnormalities (amputation, masses,
Inspect skin for moles, lesions, wounds, and lesions, cyanosis, abnormal odors
pressure ulcers (coccyx, heels).

Assess for skin breakdown, especially in

*Neurological System:*
immobile patients.
 Assess level of consciousness and
Auscultate posterior lung sounds.
orientation (alert & oriented x4).
*Conclusion:*
 Evaluate speech and cognitive function.
Summarize findings.
 Test Cranial Nerves:
Thank the patient and ensure comfort.
- *I (Olfactory):* Smell test. –
*II (Optic):* Visual acuity and peripheral vision. *Ears:*

- *III, IV, VI (Oculomotor, Trochlear,  Inspect for abnormalities, redness,

Abducens):* Pupil reaction, six cardinal fields of drainage.
gaze. –
 Palpate the outer ear and mastoid
*V (Trigeminal):* Jaw strength, facial sensation. process for tenderness.
–
 Use an otoscope to inspect the
*VII (Facial):* Smile, frown, puff cheeks. tympanic membrane (should be pearly
gray, translucent).
- *VIII (Vestibulocochlear):* Whisper test.
 Perform whisper test for hearing
- *IX, X (Glossopharyngeal, Vagus):*
assessment.
Swallowing, uvula movement, gag reflex.
*Nose:*
- *XI (Accessory):* Shoulder shrug, head
resistance. –  Inspect for alignment, septum
deviation, and drainage.
*XII (Hypoglossal):* Tongue movement.
 Assess nasal patency by occluding one
Head and Face:*
nostril at a time.
 Inspect for symmetry, involuntary
 Test sense of smell using a pleasant
movements, facial drooping.
scent.
 Palpate the cranium for masses,
Mouth and Throat:*
indentations, or infestations.
 Inspect lips, mucosa, gums, teeth,
 Palpate temporal artery bilaterally
tongue, and palate.
(check pulse strength, 2+ normal).
 Assess for sores, discoloration, dryness.
 Palpate TMJ joint while patient opens
and closes the mouth.  Inspect uvula for midline position and
movement when saying “ahh.”
 Palpate sinuses (frontal and maxillary)
for tenderness.  Test swallowing and gag reflex.

*Eyes:* Neck:*

 Inspect eyelids, sclera, conjunctiva.  Inspect trachea for midline position.

 Check for strabismus (crossed eyes) or  Palpate lymph nodes for enlargement
anisocoria (unequal pupils). or tenderness.

 Assess pupil size (3-5 mm, equal in size).  Palpate carotid arteries (one side at a
time, 2+ normal strength).
 Perform PERRLA test (Pupils Equal,
Round, Reactive to Light and  Auscultate carotid arteries with the bell
Accommodation). of the stethoscope for bruits.

 Test shoulder shrug and head resistance

for accessory nerve function.
Respiratory System:*  Assess range of motion in arms and
legs.
 Inspect chest movement, respiratory
effort, and use of accessory muscles.  Palpate for muscle strength:

 Auscultate lung sounds anteriorly, - "Squeeze my fingers." - "Push against my

laterally, and posteriorly. hands." - "Raise legs against resistance."

- Listen for crackles, wheezes, stridor, or friction  Test for arm drift (hold arms out with
rubs. eyes closed for 10 seconds).

 Check for symmetrical chest expansion.  Check Babinski reflex (normal: toes curl
inward).
Cardiovascular System:*
*Peripheral Vascular System:*
 Inspect for jugular vein distension (JVD)
at a 45-degree angle.  Inspect for skin color, temperature, and
edema.
 Auscultate heart sounds in five
locations:  Palpate pulses:

- Aortic (2nd right intercostal space) - Pulmonic - Radial, brachial, popliteal, posterior tibial,
(2nd left intercostal space) - Erb’s point (3rd left dorsalis pedis (2+ normal).
intercostal space) - Tricuspid (4th left intercostal
 Check capillary refill (<2 seconds).
space) - Mitral (5th left intercostal space, mid-
clavicular line)  Assess for pitting edema (press tibia
firmly and observe indentation).
 Assess apical pulse for one full minute.
*Integumentary System:*
 Auscultate for murmurs using the bell
of the stethoscope.  Inspect skin for lesions, moles, wounds,
rashes, or ulcers.

 Assess for pressure injuries, especially
*Abdominal System:*
on bony prominences (coccyx, heels).
 Inspect for contour, symmetry, masses,
 Evaluate skin turgor for hydration
pulsations, or hernias.
status.
 Auscultate bowel sounds in all four
Back and Posterior Assessment:*
quadrants (normal: 5-30 per minute).
 Inspect spine alignment and curvature.
 Auscultate for vascular sounds (aorta,
renal, iliac arteries).  Palpate for tenderness along the spine.
 Palpate lightly, then deeply for  Assess for any pressure sores or skin
tenderness, rigidity, or masses. breakdown.
Musculoskeletal System:*  Auscultate posterior lung sounds.
 Inspect for joint swelling, deformities,
or redness.
Conclusion:*

 Summarize findings.

 Thank the patient and ensure comfort.

 Perform hand hygiene.

 Document findings.