Head to Toe Assessment

BODY PART

◊ HEAD

Skull

Scalp/ Hair

Face

Eyes/ Vision

TECHNIQUE USED

◊ palpation

◊ inspection ◊ palpation

◊ inspection

◊ inspection ◊ palpation

FINDINGS

◊ proportional to the size of the body,

round, with prominences in the

frontal area anteriorly & the

occipital area

posteriorly, symmetrical in all

planes, gently curved

◊ scalp is white, clean, free from

masses, lumps, nits, dandruff & lesions,

with no areas of tenderness upon

palpation; hair is

black, evenly distributed & covers

the whole scalp, thick & shiny

◊ oblong shaped, symmetrical, smooth

& no involuntary muscle movements

◊ eyes are parallel & evenly placed,

symmetrical, non-protruding, with

scant amount of secretions, both

eyes black & clear;

sclera is white & clear; eyebrows

are black, symmetrical, thick,

can raise both

symmetrically & without difficulty,

evenly distributed & parallel with each

other; eyelashes are evenly

INTERPRETATION

◊ Normal

◊ Normal

◊ Normal

◊ Normal

Ears/ Hearing

◊ inspection

◊ palpation

distributed & turned

outward; upper eyelids cover a

small portion of the iris, cornea & the

sclera when the

eyes are open, when the eyes are closed

the lids meet completely,

symmetrical & the color is the same as

the surrounding

skin; lid margins are clear, without

scaling or secretions; lower

palpebral

conjunctiva are shiny, moist,

transparent & salmon pink in color;

iris are proportional to the size of the

eye, round &

symmetrical; pupils are from pinpoint to

almost the size of the iris, round,

symmetrical,

constricts with increasing light &

accommodation; able to move eyes in

full range of

direction

◊ ears are parallel,

symmetrical, proportional to the

size of the head,

bean-shaped, helix is in line with the

outer canthus of the eye, skin is the

same color as the

surrounding area & clean; ear canal is

pinkish, clean, with scant amount of

cerumen & a few cilia; able to hear

◊ Normal

Nose

Mouth/ Lips

◊ NECK

◊ THORAX &

LUNGS

◊ inspection ◊ palpation

◊ inspection

◊ palpation

◊ inspection ◊ palpation

◊ inspection

◊ palpation ◊ percussion

whisper spoken 2

feet away; 2 piercing are found in

left ear and 1 piercing in right ear

◊ nose is in midline, symmetrical, patent;

internal nares are clean, dark pink with

few cilia

◊ lips are pinkish,

symmetrical, lip margin is well-

defined, smooth & moist; gums are

pinkish, smooth,

moist, no swelling, no retraction, no

discharge; 32 teeth are present, aligned,

with no dental caries; tongue is

pinkish, slightly

rough on top, smooth along the

lateral margins, moist, shiny & freely

movable;

cheeks are pinkish, moist & smooth;

frenulum is in midline, straight &

thin; soft palate is

pinkish, smooth & moist; hard palate

is slightly pinkish; uvula is at the

center, symmetrical & freely movable

◊ proportional to the size of the body

& head, symmetrical & straight, no

palpable lumps,

masses or areas of tenderness

◊ chest contour is

symmetrical, spine is straight, no lumps,

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ HEART

◊ BREAST

◊ ABDOMEN

◊ UPPER EXTREMITIES

◊ auscultation

◊ inspection

◊ palpation

◊ percussion ◊ auscultation

◊ inspection ◊ palpation

◊ inspection

◊ auscultation ◊ percussion

◊ palpation

◊ inspection ◊ palpation

no masses, no

tender areas, with clear breath sounds

◊ no abnormal

pulsations,

pulsations are palpable & visible in

apical area

◊ symmetrical, pinkish nipples, no

cracks & discharges,

uniform in skin color, smooth &

intact, no lumps, masses &

tenderness

◊ abdominal skin

is unblemished, no scars, color is

uniform with the body color,

abdomen is

rounded with symmetric

movements caused by respiration;

umbilicus is

concave

◊ symmetrical, with visible veins, fine

hair evenly

distributed, warm, dry & elastic upon

palpation, with area of tenderness on the

left arm; palms are pinkish, warm, soft

& elastic; nails are

transparent, smooth & convex with light

pink nail beds & white translucent

tips; 5 fingers in

each hand; both shoulders, arms,

elbows, hands & wrists can be

moved in different range of motion with

◊ Normal

◊ Normal

◊ Normal

◊ Normal

◊ LOWER

EXTREMITIES

◊ inspection

◊ palpation

relative ease; c

marks of petechial rashes

◊ skin is smooth,

fine hair is evenly

distributed, absence of varicose veins,

muscles symmetrical, length

symmetrical, 5 toes in each foot, sole &

dorsal surface is

smooth with pink nail beds & white

translucent tips; both legs, knees,

ankles, & toes can

be moved in different range of

motion with relative ease; scar on both

patellar; c non pitting bipedal

edema

◊ Normal