9/9/13 Nursing Head-to-Toe Assessment Cheat Sheet - Nurseslabs

Nursing Assessment in Bullet Form

Contents [hide]
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of 1 Nursing Assessment in Bullet Form
any foul odor. He has a good skin turgor and skin’s temperature is within 1.1 Integument
normal limit. 1.2 Head
1.3 Eyes and Vision
Hair: The hair of the client is thick, silky hair is evenly distributed and has
1.4 Ears and Hearing
a variable amount of body hair. There are also no signs of infection and 1.5 Nose and Sinus
infestation observed. 1.6 Thorax and Lungs
Nails: The client has a light brown nails and has the shape of convex 1.7 Extremities
curve. It is smooth and is intact with the epidermis. When nails pressed 2 Nursing Assessment in Tabular Form
between the fingers (Blanch Test), the nails return to usual color in less
than 4 seconds.

Head
Head: The head of the client is rounded; normocephalic and symmetrical.
Skull: There are no nodules or masses and depressions when palpated.
Face: The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses.

Eyes and Vision

Eyebrows: Hair is evenly distributed. The client’s eyebrows are symmetrically aligned and showed equal movement when
asked to raise and lower eyebrows.
Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward.
Eyelids: There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks
approximately 15-20 times per minute.
Eyes
The Bulbar conjunctiva appeared transparent with few capillaries evident.
The sclera appeared white.
The palpebral conjunctiva appeared shiny, smooth and pink.
There is no edema or tearing of the lacrimal gland.
Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was
touched.
The pupils of the eyes are black and equal in size. The iris is flat and round. PERRLA (pupils equally round respond to
light accommodation), illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near 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 testing for the Extraoccular Muscle, both eyes of the client coordinately moved in unison with parallel alignment.
The client was able to read the newsprint held at a distance of 14 inches.

Ears and Hearing

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Ears: The Auricles are symmetrical and has the same color with his facial skin. The auricles are aligned with the outer
canthus of eye. When palpating for the texture, the auricles are mobile, firm and not tender. The pinna 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 nose appeared symmetric, straight and uniform in color. There was no presence of discharge or flaring. When
lightly palpated, there were no tenderness and lesions
Mouth:
The lips of the client are uniformly pink; moist, symmetric and have a smooth texture. The client was able to purse his
lips when asked to whistle.
Teeth and Gums: There are no discoloration of the enamels, no retraction of gums, pinkish in color of gums
The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture.
The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. There is a presence of thin
whitish coating.
The smooth palates are light pink and smooth while the hard palate has a more irregular texture.
The uvula of the client is positioned in the midline of the soft palate.

Neck:
The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort.
The lymph nodes of the client are not palpable.
The trachea is placed in the midline of the neck.
The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible.

Thorax and Lungs

Lungs / Chest:
The spine is vertically aligned. The right and left shoulders and 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 2-
3 cm during deep inspiration when assessing for the respiratory excursion. The client manifested quiet, rhythmic and
effortless respirations.
Heart: There were no visible pulsations on the aortic and pulmonic areas. There is no presence of heaves or lifts.
The jugular veins are not visible.
When nails pressed between the fingers (Blanch Test), the nails return to usual color in less than 4 seconds.

Abdomen: The abdomen of the client has an unblemished skin and is uniform in color. The abdomen has a symmetric
contour. There were symmetric movements caused associated with client’s respiration.

Extremities
The extremities are symmetrical in size and length.
Muscles: The muscles are not palpable with the absence of tremors. They are normally firm and showed smooth,
coordinated movements.

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Bones: There were no presence of bone deformities, tenderness and swelling.

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 complexion.

With dry skin

Hair Evenly distributed hair.With short, black and shiny

hair.With presence of pediculosis Capitis.

Nails Smooth and has intact epidermisWith short and

clean fingernails and toenails. Convex and
with good capillary refill time of 2 seconds.

Skull Rounded, normocephalic and symmetrical,

smooth and has uniform consistency.Absence of
nodules or masses.

Face Symmetrical facial movement, palpebral fissures

equal in size, symmetric nasolabial folds.

Eyes and Vision

Eyebrows Hair evenly distributed with skin intact.Eyebrows

are symmetrically aligned and have equal
movement.

Eyelashes Equally distributed and curled slightly outward.

Eyelids Skin intact with no discharges and no

discoloration.Lids close symmetrically and blinks
involuntary.

Bulbar Transparent with capillaries slightly visible

conjunctiva

Palpebral Shiny, smooth, pink

Conjunctiva

Sclera Appears white.

Lacrimal gland, No edema or tenderness over the lacrimal gland

Lacrimal sac, and no tearing.
Nasolacrimal
duct

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Cornea

Clarity and Transparent, smooth and shiny upon inspection

texture by the use of a penlight which is held in an
oblique angle of the eye and moving the light
slowly across the eye.Has brown eyes.

Corneal Blinks when the cornea is touched through a

sensitivity cotton wisp from the back of the client.

Pupils Black, equal in size with consensual and direct

reaction, pupils equally rounded and reactive to
light and accommodation, pupils constrict when
looking at near objects, dilates at far objects,
converge when object is moved toward the nose
at four inches distance and by using penlight.

Visual Fields When looking straight ahead, the client can see
objects at the periphery which is done by having
the client sit directly facing the student nurse at a
distance of 2-3 feet. The right eye is covered with
a card and asked to look directly at the student
nurse’s nose. Hold penlight in the periphery and
ask the client when the moving object is spotted.

Visual 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 same as facial skin,

symmetrical, auricle is aligned with the outer
canthus of the eye, mobile, firm, non-tender, and
pinna recoils after it is being folded.

External Ear Without impacted cerumen.

Canal

Hearing Acuity Voice sound audible.

Test

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 same distance

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 middle with no tenderness.

Mouth and Symmetrical, pale lips, brown gums and able to

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Oropharynx purse lips.

Teeth With dental caries and decayed lower molars

Tongue and Central position, pink but with whitish coating

floor of the which is normal, with veins prominent in the floor
mouth of the mouth.

Tongue Moves when asked to move without difficulty and

movement without tenderness upon palpation.

Uvula Positioned midline of soft palate.

Gag Reflex Present which is elicited through the use of a

tongue depressor.

Neck Positioned at the midline without tenderness and

flexes easily. No masses palpated.

Head movement Coordinated, smooth movement with no

discomfort, head laterally flexes, head laterally
rotates and hyperextends.

Muscle strength With equal strength

Lymph Nodes Non-palpable, non tender

Thyroid Gland Not visible on inspection, glands ascend but not

visible in female during swallowing and visible in
males.

Thorax and lungs

Posterior thorax Chest symmetrical

Spinal Spine vertically aligned, spinal column is straight,

alignment left and right shoulders and hips are at the same
height.

Breath Sounds With normal breath sounds without dyspnea.

Anterior Thorax Quiet, rhythmic and effortless respiration

Abdomen Unblemished skin, uniform in color, symmetric

contour, undistended.

Abdominal Symmetrical movements cause by respirations.

movements

Auscultation of With audible sounds of 23 bowel sounds/minute.

bowel sounds

Upper Extremities Without scars and lesions on both extremities.

Lower Extremities With minimal scars on lower extremities

Muscles Equal in size both sides of the body, smooth

coordinated movements, 100% of normal full
movement against gravity and full resistance.
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Bones and Joints No deformities or swelling, joints move smoothly.

Mental Status

Language Can express oneself by speech or sign.

Orientation Oriented to a person, place, date or time.

Attention span Able to concentrate as evidence by answering the

questions appropriately.

Level of A total of 15 points indicative of complete　

Consciousness orientation and alertness. E4V5M6

Motor Function

Gross Motor and

Balance

Walking gait Has upright posture and steady gait with

opposing arm swing unaided and maintaining
balance.

Standing on one Maintained stance for at least five (5) seconds.

foot with eyes
closed

Heel toe walking Maintains a heel toe walking along a straight line

Toe or heel Able to walk several steps in toes/heels.

walking

Fine motor test for

Upper Extremities

Finger to nose test Repeatedly and rhythmically touches the nose.

Alternating Can alternately supinate and pronate hands at

supination and rapid pace.
pronation of hands
on knees

Finger to nose and Perform with coordinating and rapidity.

to the nurse’s
finger

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

sensation when touched with needle and cotton.
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