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NUR 317L Head-to-Toe Assessment 8
Expanding Family and Community (West Coast University)
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NUR 317L Physical Assessment Check-off
15minute Head-to-Toe Assessment
Student name: _________________________ Partner: _________________________Score: _____________
***There is a 15 minute time limit for completing check off, so practice with a timer until you are proficient.
General 1 pt. ½ pt. 0 pt. Comments /5
Infection control /hand hygiene
Patient identification & allergies
Emergency equipment available
Vital signs completed prior to check off-
report abnormal, otherwise state stable
Assess pain (FLACC, Wong-Baker FACES
etc.)
Head 1 pt. ½ pt. 0 pt. Comments /12
Assess orientation: person, place, time, &
event (depending on age)
Assess mood & general well being
Skin inspection
Head circumference if applicable (hospital
policy)
Fontanel (anterior, posterior)
Inspect nose
Inspect ears
Inspect mouth
Lymph node palpation (child or
adolescent)
Auscultate carotid arteries for bruits
(adolescent)
Palpate carotid pulses- one at a time &
compare with radial pulse (child or
adolescent)
Assess JVD in neck (child or adolescent)
Cranial nerves 1 pt. ½ pt. 0 pt. Comments /14
CN I: Olfactory- smell
CN II: Optic- tracks face/intact visual acuity
CN III, IV & VI: Oculomotor, Trochlear,
Abducens- eyes/PERRL
CN III, IV & VI: Oculomotor, Trochlear,
Abducens- eyes/cardinal fields of gaze
CN V: Trigeminal- sucking reflex/clench
teeth
CN VII: Facial nerve- symmetric facial
movements, differentiate salty/sweet
VIII: Acoustic- tracks sound/intact hearing
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CN IX: Glossopharyngeal/Vagus- gag
reflex, taste sour sensations
CN X: Vagus- swallowing, speech, uvula
midline
CN XI: Spinal accessory- moves shoulders
symmetrically, equal strength
CN XII: Hypoglossal- open mouth when
nares are occluded/ tongue midline, move
tongue in all directions
Assess gait & balance
Cerebellar function: finger to nose,
Romberg, if applicable (stand with slight
sway when eyes are closed)
Infant reflexes, if applicable
Chest 1 pt. ½ pt. 0 pt. Comments /6
Assess skin integrity, color, turgor,
warmth, & edema
Inspect thoracic cage for symmetry,
muscle development, & configuration
Verbalizes respiratory effort
(pattern/rhythm): symmetric, no
retractions
Auscultate anterior breath sounds
Auscultate lateral breath sounds
Auscultate posterior breath sounds
Auscultate with diaphragm (state 1 pt. ½ pt. 0 pt. Comments /8
landmarks, S1 & S2 sounds)
Auscultate aortic valve (2nd intercostal,
right sternal border), S2 > S1
Auscultate pulmonic valve (2nd intercostal
space, left sternal border), S2 > S1
Auscultate Erb’s point (3rd intercostal
space, left sternal border), S1 = S2, USE
bell of stethoscope
Auscultate tricuspid valve (4th intercostal
space, left sternal border), S1 > S2
Auscultate mitral valve/apex of heart (5th
intercostal space, left midclavicular line),
S1 > S2
S3 (can be normal= Ventricular wall not
expanding fully, causing early diastole. Left
side lying 4th ICS). Loud is normal, high-
pitched NOT normal (HF).
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S4 (abnormal= decreased ventricular
compliance with late diastole) Known as
an atrial gallop. HF.
Auscultates apical heart rate
Upper Extremities 1 pt. ½ pt. 0 pt. Comments /4
Assess skin integrity, color, turgor,
warmth, & edema
Muscle strength and Joint ROM
Capillary refill bilaterally
BUE pulses (radial, brachial)
Abdomen 1 pt. ½ pt. 0 pt. Comments /4
Abdominal inspection
Abdominal auscultation, all 4 quadrants
Abdominal percussion, all 4 quadrants
Abdominal light palpation, all 4 quadrants
(Do not palpate a Wilms Tumor patient)
Lower Extremities 1 pt. ½ pt. 0 pt. Comments /4
Assess skin integrity, color, turgor,
warmth, & edema
BLE strength and joint ROM
Capillary refill bilaterally
Pulses (popliteal, dorsalis pedis)
Genitalia 1 pt. ½ pt. 0 pt. Comments /3
Inspection of penis, scrotum, labia, clitoris,
urethral meatus
Inspection of anus
Inspection of urine and stool, if applicable
1) completed within 15 minutes
2) infection control maintained
3) assessment is complete & organized
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