NR 302: Health Assessment I: HEAD TO CHEST RETURN DEMONSTRATION
INTRODUCTIONS:
1. Pull curtain for privacy
2. Perform hand hygiene
3. Hello Mr. Smith – My name is Devin and I will be your student nurse today
4. Today I will be doing a head to chest assessment on you, it will take about 20
minutes and it will involve me touching your head and face and exposing your chest.
Is that OK?
5. OK great. Now before we begin, can you please verify your name and date of birth
for me?
6. Do you have any allergies that I should be aware of before we begin?
7. Are you in any pain? On a scale of 0-10, 0 being no pain at all and 10 being the
worst pain you’ve ever had in your life?
GENERAL APPEARANCE:
1. PHYSICAL APPEARANCE:
• AGE
• SKIN COLOR
• FACIAL FEATURES
• SIGNS OF ACUTE DISTRESS
• VISIBLE DEVICES AND EQUIPMENT
• Patient’s age is appropriate to what is stated in the chart
• Skin color is appropriate to ethnic background
• Facial features are symmetric with movement
• No signs of acute distress
• No visible devices or equipment noted
2. BODY STRUCTURE:
• STATURE
• NUTRITION
• SYMMETRY
• POSTURE
• POSITION
• BODY BUILD AND CONTOUR
• OBVIOUS PHYSICAL DEFORMITIES
, • Patient’s stature is appropriate to height and weight
• Patient appears to be well nourished
• Body parts look equal and symmetrical bilaterally
• Patient is lying comfortable in bed with the head of bed at a 30 degree angle
• Patient’s contour is of medium build which is appropriate to stature
• There are no obvious physical deformities
3. LEVEL OF CONSCIOUSNESS:
• LOC-alert and oriented to person, place, time, and situation
• Mr. Smith do you know where you are today?
• Do you know why you are here?
• Do you know what day it is?
• Do you know who the president is?
• Good. Patient is alert and oriented to person, place, time, and situation
4. BEHAVIOR:
• FACIAL EXPRESSION
• MOOD AND AFFECT
• SPEECH
• DRESS
• PERSONAL HYGIENE & GROOMING
• Patient’s facial expressions are neutral and appropriate to situation
• Patient’s mood and affect are comfortable and cooperative with
the assessment
• Patient’s speech is articulate, appropriate and clear
• Patient’s dress is appropriate to situation
• Patient’s hygiene is good – appears to be clean and well-groomed
appropriate to age
SKIN & NAILS:
1. INSPECT SKIN CONDITION
• ASSESS FOR COLOR, LESIONS, INCISIONS, WOUNDS, RASHES, AND TATTOOS
2. INSPECT NAILS
• ASSESS COLOR, SHAPE, AND CONTOUR
3. ASSESS CAPILLARY REFILL (VERBALIZE RATING)
INTRODUCTIONS:
1. Pull curtain for privacy
2. Perform hand hygiene
3. Hello Mr. Smith – My name is Devin and I will be your student nurse today
4. Today I will be doing a head to chest assessment on you, it will take about 20
minutes and it will involve me touching your head and face and exposing your chest.
Is that OK?
5. OK great. Now before we begin, can you please verify your name and date of birth
for me?
6. Do you have any allergies that I should be aware of before we begin?
7. Are you in any pain? On a scale of 0-10, 0 being no pain at all and 10 being the
worst pain you’ve ever had in your life?
GENERAL APPEARANCE:
1. PHYSICAL APPEARANCE:
• AGE
• SKIN COLOR
• FACIAL FEATURES
• SIGNS OF ACUTE DISTRESS
• VISIBLE DEVICES AND EQUIPMENT
• Patient’s age is appropriate to what is stated in the chart
• Skin color is appropriate to ethnic background
• Facial features are symmetric with movement
• No signs of acute distress
• No visible devices or equipment noted
2. BODY STRUCTURE:
• STATURE
• NUTRITION
• SYMMETRY
• POSTURE
• POSITION
• BODY BUILD AND CONTOUR
• OBVIOUS PHYSICAL DEFORMITIES
, • Patient’s stature is appropriate to height and weight
• Patient appears to be well nourished
• Body parts look equal and symmetrical bilaterally
• Patient is lying comfortable in bed with the head of bed at a 30 degree angle
• Patient’s contour is of medium build which is appropriate to stature
• There are no obvious physical deformities
3. LEVEL OF CONSCIOUSNESS:
• LOC-alert and oriented to person, place, time, and situation
• Mr. Smith do you know where you are today?
• Do you know why you are here?
• Do you know what day it is?
• Do you know who the president is?
• Good. Patient is alert and oriented to person, place, time, and situation
4. BEHAVIOR:
• FACIAL EXPRESSION
• MOOD AND AFFECT
• SPEECH
• DRESS
• PERSONAL HYGIENE & GROOMING
• Patient’s facial expressions are neutral and appropriate to situation
• Patient’s mood and affect are comfortable and cooperative with
the assessment
• Patient’s speech is articulate, appropriate and clear
• Patient’s dress is appropriate to situation
• Patient’s hygiene is good – appears to be clean and well-groomed
appropriate to age
SKIN & NAILS:
1. INSPECT SKIN CONDITION
• ASSESS FOR COLOR, LESIONS, INCISIONS, WOUNDS, RASHES, AND TATTOOS
2. INSPECT NAILS
• ASSESS COLOR, SHAPE, AND CONTOUR
3. ASSESS CAPILLARY REFILL (VERBALIZE RATING)
