Nursing Head-to-Toe Assessment Cheat Sheet - Nurseslabs.pdf

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Nur si ng Head- to- Toe Assessment Cheat Sheet - Nur sesl abs

Nursing Assessment in Bullet Form Contents [ hide hide]]

Integument Skin: Sk in: The client’s client’s skin is un if iform orm in color, unblemished unblemished and no presen ce of 

1 Nursing Assessment in Bullet Form

any fou l odor. He He has a goo d s ki kin n turgo r and skin’s temperature temperature is within within

1.1 Integument

normal limit.

1.2 Head

Hair: Hai r: The ha ir of the client is th ick ick,, silky silky hair is is ev enly distributed and has a variable variable amoun amoun t of bod y hair. There are also also no s igns o f infection infection and

1.3 Eyes and Vision 1.4 Ears and Hearing 1.5 Nose and Sinus

infestation inf estation o bserved.

1.6 T horax and Lungs Lungs

 Nailss : The client h as a light brown nails  Nail n ails and has th thee sh ape o f conv ex

1.7 Extremities

curve. It is is s moot h and is intact with with th e epidermis. epidermis. When n ail ailss p ress ed

2 Nursing Assessment in T abul abular ar Form

 bet ween th e fing fing ers (Blanc (Blanc h Tes t), the n ail ailss return ret urn to t o us ual color in less than 4 seconds.

Head Head: The head o f the client client is round ed; n orm ormoceph oceph ali alicc and sy mmetri etrical. cal. Skull Sk ull:: There are are no nodules or mass mass es and dep ress ions when palpated. Face: The face of the client client app eare eared d s mooth and h as u nif niform orm cons istency and with no p resence of nodu le less or mass mass es.

Eyes and Vision Eyebrows: Hair Hair is is even ly distributed. Th e client’s client’s eyebrows are sy mmetrical etrically ly aligned aligned and sh owed eq ual movement movement when asked to raise and lower eyebrows. Eyelashe s: Eyelashe s app eared to be equally equally distributed and curled slight slight ly outward. outward. Eyeli yelids ds : There There were were no p resence o f disch disch arges, no discoloration and li lids ds clos e s ymm ymmetrically etrically wit with invo luntary blinks app rox roxim imately ately 1515-20 20 times times per minut inute. e. Eyes The Bulbar conjunctiva ap peared trans parent wi with th few capill capillari aries es evident. The s cler cleraa appea red white. white. The palpebral conjunctiva appeared shiny, smooth and pink. There is n o e dema or tearing tearing of th e lacrim lacrimal gland. Cornea Cor nea is trans parent, smooth and s hiny and the d etail etailss o f the iris iris are visible. visible. The client client b li links nks when t he cornea was touched. The pu pil pilss o f the eyes are black and equa l in in s iz ize. e. The iris iris is flat flat an d roun d. PERR PERRL LA (pup il ilss eq uall ually y roun d resp ond to light li ght accomm accommodat odat ion), ill illum uminated inated an d n on-il on-illum luminated inated p upils con st ri ricts cts . Pupils Pupils cons tri trict ct when looki looking ng at n ear object and dilate at far object. Pupils converge when object is moved towards the nose. When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. When tes ting for the Extraoccular Extraoccular Mus cle, both ey es of the client coo rdinately move move d in un ison with parallel parallel alignm alignment. ent. The client client was ab le to read the n ewsprint held at a dista nce of 14 inches.

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Nursing Head-to-Toe Assessment Cheat Sheet - Nurseslabs

Ears: The Au ricles are s ymmetrical and h as the same color with his facial skin. The a uricles are aligned with the out er  canth us of eye. Wh en p alpating for the texture, the auricles a re mobile, firm and not tend er. The p inna recoils when folded. During the assessment of Watch tick test, the client was able to hear ticking in both ears.

Nose and Sinus  Nose: The no se app eared s ymmetric, straigh t and uniform in color. There was n o presen ce of discharge or flaring. Wh en lightly palpated, there were no tenderness and lesions Mouth: The lips of th e client are uniformly pink; moist, s ymmetric and have a s moot h t exture. The client was ab le to p urse h is lips when as ked to whistle. Teeth a nd Gums: There are no discoloration o f the en amels, no retraction of gu ms, p inkish in co lor of gums The bu ccal mucos a of the client ap peared as uniformly pink; moist, s oft, glist ening an d with elastic texture. The ton gue o f the client is cen trally pos itioned . It is pink in color, moist an d s light ly roug h. There is a p resence o f thin whitish coating. The s moot h pa lates are light pink and s moot h while the hard pa late has a more irregular texture. The uv ula of the client is p os itioned in the midline of the so ft palate.

 Neck: The neck muscles are equ al in s ize. The client s howed co ordinated, s moot h he ad movement with no disco mfort. The lymph nodes of the client are not palpable. The trachea is placed in the midline of the n eck. The thyroid gland is not visible on inspection and the g lands ascend during swallowing but are not visible.

Thorax and Lungs Lungs / Chest: The s pine is vertically aligned. The right and left sh oulders an d hips are of the same height.

The chest wall is intact with no tenderness and masses. There’s a full and symmetric expansion and the thumbs separate 23 cm during deep inspiration when as ses sing for the respiratory excursion. The c lient manifest ed qu iet, rhyt hmic and effortless respirations. Heart: There were no visible pulsations on t he aortic and p ulmonic areas. There is no pres ence of heav es o r lifts . The jugular veins are not v isible. When nails pressed between the fingers (Blanch Tes t), the nails return to usu al color in less than 4 seconds .

Abd omen: The abd omen of the client has an un blemished skin and is uniform in color. The ab domen has a sy mmetric con tou r. There were sy mmetric movements caus ed as so ciated with client’s resp iration.

Extremities The extremities are symmetrical in size and length. Mus cles: The mus cles are not palpable with t he ab sen ce of tremors. They are normally firm and sh owed s moot h, coordinated movements. nurseslabs.com/nursing-assessment-cheat-sheet/

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Nursing Head-to-Toe Assessment Cheat Sheet - Nurseslabs

Bones: There were no p resence o f bone d eformities, ten dernes s an d s welling. Joints: There were no swelling, tenderness and joints move smoothly.

Nursing Assessment in Tabular Form ASSESSMENT

FINDINGS

Integumentary Skin

When skin is pinched it goes to previous state immediately (2 seconds). With fair com plexion. With dry skin

Hair

Evenly distributed hair .With   s hort, black and s hiny hair.With presence of pediculosis Capitis.

Nails

Smooth and has intact epidermi sWith short and clean fingernails and toenails. Convex and with good capillary refill time of 2 s econds.

Skull

Rounded, normocephalic and symmetrical, sm ooth and has uniform cons istency.Absence of  nodules or mass es.

Face

Symmetrical facial movement, palpebral fissures equal in size, symm etric nasol abial folds.

Eyes and Vision Eyebrows

Hair evenly distributed with skin intact.Eyebrows are symm etrically aligned and have equal movement.

Eyelashes

Equally distributed and curled slightly outward.

Eyelids

Skin intact with no dis charges and no discoloration.Lids clos e symme trically and blinks involuntary.

Bulbar  conjunctiva

Transparent with capillaries slig htly visi ble

Palpebral Conjunctiva

Shiny, sm ooth, pink

Sclera

Appears white.

Lacrimal gland, Lacrimal sac, Nasolacrimal duct

No edem a or tenderness over the lacrimal gl and and no tearing.

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Cornea Clarity and texture

Transparent, sm ooth and shiny upon inspection by the use of a penlig ht which is hel d in an oblique ang le of the eye and m oving the light slow ly across the eye.Has brown eyes .

Corneal sensitivity

Blinks when the cornea is touched through a cotton wis p from the back of the client.

Pupils

Black, equal in size with consensual and direct reaction, pupils equally rounded and reactive to light and accomm odation, pupils constrict when looking at near objects, dilates at far objects, converge when o bject is m oved toward the nos e at four inches d istance and by using penli ght.

Vi sua l Fi el ds

When loo ki ng s trai gh t ah ead , the cl ient ca n s ee objects at the periphery which is done by having the client sit directly facing the s tudent nurse at a dis tance of 2-3 feet. The righ t eye is covered wi th a card and as ked to look directly at the student nurse’s nose . Hold penlight in the periphery and ask the client when the mo ving object is s potted.

Vis ual Acuity  Able to identify letter/read in the newsprints at a distance of fourteen inches . She was able to read the newsprint at a distance of 8 inches. Ear and Hearing  Auricles

Color of the auricles is s am e as facial s kin, symm etrical, auricle is al igned with the outer  canthus of the eye, m obile, firm, non-tender, and pinna recoils after it is bein g folded.

External Ear  Canal

Without imp acted cerumen.

Hearing Acuity Test

Voice sound au dible.

Watch Tick Test

Able to hear ticking on right ear at a distance of  one inch and was able to hear the ticking on the left ear at the sam e dis tance

Nose and sinuses External Nose

Symmetric and straight, no flaring, uniform in color, air moves freely as the clients breathes through the nares.

Nasal Cavity

Mucosa is pink, no lesions and nasal septum intact and in middl e with no tenderness .

Mouth and

Sym metrical, pale lips , brown gum s and able to

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Oropharynx

purse lips.

Teeth

With dental caries and decayed lower molars

Tongue and floor of the mouth

Central position, pink but with whitis h coating which is n ormal, with veins p rominent in the floor  of the mouth.

Tongue movement

Moves when asked to move without difficulty and without tenderness upon palpation.

Uvula

Positioned midline of soft palate.

Gag Reflex

Pres ent w hich is elicited through the us e of a tongue depressor.

Neck

Positioned at the midline without tenderness and flexes easily. No masses palpated.

Head movement

Coordinated, smooth movement with no discom fort, head laterally flexes, h ead laterally rotates and hyperextends.

Mus cl e s tren gth

Wi th e qua l s trength

Lym ph Nodes

Non-palpable, non tender  

Thyroid Gland

Not visible on inspection, glands ascend but not visi ble in female during sw allowing and visible in males.

Thorax and lungs Pos te ri or tho ra x Spinal alignment

Breath Sounds  Anterior Thorax

C he st s ym m etrical Spine vertically aligned, spin al colum n is straight, left and right shoulders and hips are at the sam e height. With normal breath sounds without dyspnea. Quiet, rhythmi c and effortles s res piration

 Abdom en

Unblem is hed s kin, uniform in color, symm etric contour, undistended.

 Abdom inal movements

Symm etrical movemen ts cause by respirations.

 Aus cultation of  bowel sounds

With audible sounds of 23 bowel sounds/minute.

Upper Extremities

Without scars and lesions on both extremities.

Lower Extremities

With minimal scar s on lower extre mities

Muscles

Equal in s ize both sides of the body, s mooth coordinated movements, 100% of normal full movement agains t gravity and full res istance.

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Bones and Joints

No deformities or swelling, joints move smoothly.

Mental Status Language

Can expres s oneself by speech or s ign.

Orientation

Oriented to a pers on, place, date or tim e.

 Attention span

Able to concentrate as evidence by ans wering the questions appropriately.

Level of  Consciousness

 A total of 15 points indi cative of complete orientation and alertness. E4V5M6

Motor Function Gross Motor and Balance Walking gait

Has upright posture and steady gait with opposing arm s wing unaided and maintaining balance.

Standing on one foot with eyes closed

Maintained s tance for at least five (5) s econds.

Heel toe walking

Maintains a heel toe walking along a straight line

Toe or heel walking

 Able to walk s everal s teps in toes /heels .

Fine motor test for  Upper Extremities Finger to nose test

Repeatedly and rhythmically touches the nose.

 Alternating supination and pronation of hands on knees

Can alternately supin ate and pronate hands at rapid pace.

Finger to nos e and to the nurse’ s finger 

Perform with coordinating and rapidity.

Fingers to fingers

Perform with accuracy and rapidity.

Fingers to thumb

Rapidly touches each finger to thumb with each hand.

Fine motor test for  the Lower  Extremities Pain sensation

Able to discriminate between sharp and dull sens ation when touched with needle and cotton.

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