NSG 2317 - HEAD TO TOE ASSESSMENT (REVIEW)
UPDATED ACTUAL Questions and CORRECT Answers
17 step order of Head to toe Assessment? 1. HAND HYGIENE
Name assessment techniques in each? 2. HEALTH HISTORY (SUBJECTIVE DATA)
3. GENERAL SURVEY
4. MEASUREMENTS
5. VITAL SIGNS
6. DERM - SKIN: Inspection & Palpation
7. HEENT - HEAD, EYES, EARS, NOSE, NECK, THOAT - Inspection, palpation (not for
eyes), neck: auscultation
8. RESPIRATORY - Inspection, Palpation, Percussion, Auscultation
9. CARDIOVASCULAR - Inspection, palpation, auscultation
10. BREASTS - Inspection, palpation
11. GASTROINTESTINAL - inspection, auscultation, percussion, palpation
12. EXTREMITIES - Circulation, Movement, Sensation
13. NEURO & MSK - Tests
14. GU - Male (inspection, palpation), Female (inspection)
15. CLOSING
16. CRITICAL FINDINGS - Objective & Subjective
17. DOCUMENTATION
HAND HYGIENE — "4 Moments" SLIDE 21 1. Before entering the patient room.
2. Before an aseptic procedure.
3. After body fluid exposure risk.
4. After leaving the patient environment.
, GENERAL HEALTHH HISTORY - 8 step sequence 1. Biographical data
2. Reason for seeking care (pt. own words)
3. Current health (if no issues) or Illness History - PQRSTU
4. Past Medical Hx
5. Family Medical History
6. Review of Systems (Subjective)
7. Organ Inventory - Transgender patients
8. Functional Assessment / ADLs
4 parts of General survey and important findings in each? 1. PHYSICAL APPEARANCE = LOC, Age, Sex/gender, Skin color, Facial expressions
-( also: Dress, Hygiene, Physical deformities)
2. BODY STRUCTURE = Posture, Position, Body build/contour, Symmetry, Nutritional
Status
3. MOBILITY = GAIT, ROM, Assistive devices use, involuntary movement, ability to
rise from seated positions
4. BEHAVIOR = Facial expressions, Mood + affect, Dress, Personal Hygiene, Speech
Additional part to assess during GENERAL SURVERY? HEARING
4 main Measurements to perform on patient? 2 additional 1. HEIGHT (STATURE)
measurements if needed? 2. WEIGHT
3. BMI calculation
4. WAIST-TO-HIP Circumference (better predictor of health risk than BMI)
5. HEAD Circumference = Infants/newborns
6. Snellen eye chart = if vision assessment needed
6 VITAL SIGNS? 1. Temperature = 35.8 - 37.3°C
2. Heart rate (Radial Pulse) = 50-95 bpm
-note: rhythm, strength, equality
3. Respiratory rate = 10-20 breaths/min
-note: rhythm, depth, effort, sound
4. SpO2 = >95%
5. Blood pressure = 120/80
-Acceptable range: 95-140 systolic, 60-90 diastolic
6. Pain = Numeric scale (0-10)
DERM - Inspection (6), Palpation (5)? SLIDE 20 INSPECTION
1. Color
2. Moisture
3. Lesions
4. Edema
5. Hair pattern
6. Nails = CAPILLARY REFILL, color, angle, shape
PALPATION
1. TEMPERATURE
2. Moisture
3. TURGOR & MOBILITY
4. TEXTURE
5. THICKNESS
-REMEMBER ABCDE
HEENT - Head & Face: Inspection (head/face), Palpation 1. HEAD = Inspect & Palpate scalp, hair, skull
(head/face), Cranial nerves? 2. FACE = INSPECT facial expression & symmetry
-PALPATE = Maxillary & Frontal sinuses, Temporal artery (TMJ)
3. Test Cranial nerves: V (trigeminal) & VII (facial)
UPDATED ACTUAL Questions and CORRECT Answers
17 step order of Head to toe Assessment? 1. HAND HYGIENE
Name assessment techniques in each? 2. HEALTH HISTORY (SUBJECTIVE DATA)
3. GENERAL SURVEY
4. MEASUREMENTS
5. VITAL SIGNS
6. DERM - SKIN: Inspection & Palpation
7. HEENT - HEAD, EYES, EARS, NOSE, NECK, THOAT - Inspection, palpation (not for
eyes), neck: auscultation
8. RESPIRATORY - Inspection, Palpation, Percussion, Auscultation
9. CARDIOVASCULAR - Inspection, palpation, auscultation
10. BREASTS - Inspection, palpation
11. GASTROINTESTINAL - inspection, auscultation, percussion, palpation
12. EXTREMITIES - Circulation, Movement, Sensation
13. NEURO & MSK - Tests
14. GU - Male (inspection, palpation), Female (inspection)
15. CLOSING
16. CRITICAL FINDINGS - Objective & Subjective
17. DOCUMENTATION
HAND HYGIENE — "4 Moments" SLIDE 21 1. Before entering the patient room.
2. Before an aseptic procedure.
3. After body fluid exposure risk.
4. After leaving the patient environment.
, GENERAL HEALTHH HISTORY - 8 step sequence 1. Biographical data
2. Reason for seeking care (pt. own words)
3. Current health (if no issues) or Illness History - PQRSTU
4. Past Medical Hx
5. Family Medical History
6. Review of Systems (Subjective)
7. Organ Inventory - Transgender patients
8. Functional Assessment / ADLs
4 parts of General survey and important findings in each? 1. PHYSICAL APPEARANCE = LOC, Age, Sex/gender, Skin color, Facial expressions
-( also: Dress, Hygiene, Physical deformities)
2. BODY STRUCTURE = Posture, Position, Body build/contour, Symmetry, Nutritional
Status
3. MOBILITY = GAIT, ROM, Assistive devices use, involuntary movement, ability to
rise from seated positions
4. BEHAVIOR = Facial expressions, Mood + affect, Dress, Personal Hygiene, Speech
Additional part to assess during GENERAL SURVERY? HEARING
4 main Measurements to perform on patient? 2 additional 1. HEIGHT (STATURE)
measurements if needed? 2. WEIGHT
3. BMI calculation
4. WAIST-TO-HIP Circumference (better predictor of health risk than BMI)
5. HEAD Circumference = Infants/newborns
6. Snellen eye chart = if vision assessment needed
6 VITAL SIGNS? 1. Temperature = 35.8 - 37.3°C
2. Heart rate (Radial Pulse) = 50-95 bpm
-note: rhythm, strength, equality
3. Respiratory rate = 10-20 breaths/min
-note: rhythm, depth, effort, sound
4. SpO2 = >95%
5. Blood pressure = 120/80
-Acceptable range: 95-140 systolic, 60-90 diastolic
6. Pain = Numeric scale (0-10)
DERM - Inspection (6), Palpation (5)? SLIDE 20 INSPECTION
1. Color
2. Moisture
3. Lesions
4. Edema
5. Hair pattern
6. Nails = CAPILLARY REFILL, color, angle, shape
PALPATION
1. TEMPERATURE
2. Moisture
3. TURGOR & MOBILITY
4. TEXTURE
5. THICKNESS
-REMEMBER ABCDE
HEENT - Head & Face: Inspection (head/face), Palpation 1. HEAD = Inspect & Palpate scalp, hair, skull
(head/face), Cranial nerves? 2. FACE = INSPECT facial expression & symmetry
-PALPATE = Maxillary & Frontal sinuses, Temporal artery (TMJ)
3. Test Cranial nerves: V (trigeminal) & VII (facial)
