Chamberlain College of Nursing - NURSING NR 324Head to Toe Assessment

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Head to Toe Assessment Knock on door, perform hand hygiene, introduce yourself, say you’re going to do a Head to Toe Assessment and that it is going to take about 15 to 20 minutes. Identify patie... nt – Ask for their Name and DOB. Ask patient if they have any allergies. Ask on a scale of 0-10 what their level of pain is. Neurological System – Ask patient if they know where they are, what day it is, and ask who is the president of the United States. Patient is Awake, Alert, and Oriented x3. General Appearance – Inspect overall appearance. Assess if patient looks appropriate for their age and culture (skin tone, weight, height). No signs of depression/distress. Assess for symmetry of body structure. Posture is erect. No obvious signs of physical deformities. Patient is dressed appropriate for weather. Speech is clear. No tattoos. 2 ear piercings. Ask patient if it is ok to touch them. Skin and Nails – Inspect skin. Note any lesions. Check for capillary refill (less than 3 seconds) and skin turgor. Assess temperature of with back of hand. Skin is warm and dry. Head and Face Palpate head (Normocephalic). Hair is evenly distributed. No signs of infestations or lesions. Palpate lymph nodes (Parotid, Preauricular, Postauricular, Occipital, Submandibular, Submental, and Jugulogastric) Cranial Nerve # 5 (Trigeminal) – Ask to clench teeth. Assess masseter and temporal contraction. Ask to close eyes and test for sensation. Ask to blink [Show More]

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