Complete Head-to-Toe Physical Assessment Cheat Sheet
FNP 654Complete Head-to-Toe Physical
Assessment Cheat Sheet
Complete Head-to-Toe PhysicalAssessment
Cheat Sheet
By Matt Vera - Feb 18, 2012
Nursing assessment is an important step of the whole nursing process. Assessment can be
called the “base or foundation” of the nursing process. With a weak or incorrect assessment,
nurses can create an incorrect nursing diagnosis and plans therefore creating wrong
interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet
that you can print and use to guide you throughout the first step of the nursing process.
SEE ALSO: Nursing Health Assessment Mnemonics & Tips
Physical Assessment
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He
has a good skin turgor and skin’s temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount
of body hair. There are also no signs of infection and infestation observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and
is intact with the epidermis. When nails pressed 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
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, Complete Head-to-Toe Physical Assessment Cheat Sheet
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 Extraocular 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
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, Lungs, and Abdomen
2/6
FNP 654Complete Head-to-Toe Physical
Assessment Cheat Sheet
Complete Head-to-Toe PhysicalAssessment
Cheat Sheet
By Matt Vera - Feb 18, 2012
Nursing assessment is an important step of the whole nursing process. Assessment can be
called the “base or foundation” of the nursing process. With a weak or incorrect assessment,
nurses can create an incorrect nursing diagnosis and plans therefore creating wrong
interventions and evaluation. To prevent those kind of scenarios, we have created a cheat sheet
that you can print and use to guide you throughout the first step of the nursing process.
SEE ALSO: Nursing Health Assessment Mnemonics & Tips
Physical Assessment
Integument
Skin: The client’s skin is uniform in color, unblemished and no presence of any foul odor. He
has a good skin turgor and skin’s temperature is within normal limit.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount
of body hair. There are also no signs of infection and infestation observed.
Nails: The client has a light brown nails and has the shape of convex curve. It is smooth and
is intact with the epidermis. When nails pressed 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
1/6
, Complete Head-to-Toe Physical Assessment Cheat Sheet
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 Extraocular 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
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, Lungs, and Abdomen
2/6
