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 thechart
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 thehead 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 thepresident 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
theassessment
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 thechart
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 thehead 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 thepresident 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
theassessment
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)
