Head-To-Toe Assessment



By the end of the topic students should be able to:

  1. Define physical assessment
  2. Describe the four techniques used in physical assessment
  3. Know how to do a head to toe assessment
Physical assessment
  • a systematic data collection method that uses the senses of sight, hearing, smell and touch to detect health problems.There are four techniques used in physical assessment and these are: Inspection, palpation, percussion and auscultation. Usually history taking is completed before physical examination
  • It’s the use of vision to distinguish the normal from the abnormal findings.Body parts are inspected to identify color, shape, symmetry, movement, pulsation and texture.

Principles of inspection

  • Availability of adequate light
  • Position and expose body part to view all surfaces
  • Inspect each area for size, shape, color, symmetry, Position and abnormalities.
  • If possible compare each area inspected with the same area on the opposite side.
  • Use additional light to inspect body cavities
  • It involves use of hands to touch body parts for data collection.
  • The nurse uses fingertips and palms to determine the size, shape, and configuration of underlying body structure and pulsation of blood vessels.
  • It help to detect the outline of organs such as thyroid, spleen or liver and mobility of masses.
  • It detects body temperature, moisture, turgor, texture, tenderness, thickness, and distention.

Principles of palpation

  • Help client to relax and be comfortable because muscle tension impairs effective assessment.
  • Advise client to take slow deep breaths during palpation
  • Palpate tender areas last and note nonverbal signs of discomfort.
  • Rub hands to warm them, have short fingernails and use gentle touch.
  • It is the technique in which one or both hands are used to strike the body surface to produce a sound called percussion note that travels through body tissue.
  • The character of the sound determines the location, size and density of underlying structure to verify abnormalities.
  • An abnormal sound suggest a mass or substance like air, fluid in an organ or cavity.
  • It involves listening to sounds and a stethoscope is mostly used.
  • Various body systems like cardiovascular, respiratory and gastrointestinal have characterized sounds.
  • Bowel, breath, heart and blood movement sounds are heard using the stethoscope.
  • It is important to know the normal sound to distinguish from abnormal.
Preparation for physical exam
  • Infection prevention– Follow IP precaution through out procedure
  • Environment– P/A requires privacy and away from other destructors throughout
  • Equipment– Get all the necessary equipment, other equipment needs to be warmed before being placed on the body e.g. rubbing diaphragm of the stethoscope briskly between hands.
  • Patient preparation– Prepare the patient physically and make the patient comfortable throughout the physical assessment for successful exam.Explain to the patient everything to be done.
General survey
  • The assessment of the patient/client begins on the first contact.
  • It includes apparent state of health , level of consciousness, and signs of distress.
  • The general height, weight, and build can be noted including skin color, dressing, grooming, personal hygiene, facial expression, gait, odor, posture and motor activity.

NOTE: If there is a sign of acute distress comprehensive health assessment is deferred until when patient is stable.

Vital signs
  • Assessment of vital signs is the first in physical assessment because positioning and moving the client during examination interferes with obtaining accurate results.
  • Specific vital signs can be also obtained during assessment of individual body system.
Skull, Scalp & Hair
  • Observe the size, shape and contour of the skull.
  • Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
  • Palpate the head by running the pads of the fingers over the entire surface of skull; inquire about tenderness upon doing so. (wear gloves if necessary)
  • Observe and feel the hair condition.
Normal Findings:


  • Generally round, with prominences in the frontal and occipital area. (Normocephalic).
  • No tenderness noted upon palpation.


  • Lighter in color than the complexion.
  • Can be moist or oily.
  • No scars noted.
  • Free from lice, nits and dandruff.
  • No lesions should be noted.
  • No tenderness or masses on palpation.


  • Can be black, brown or burgundy depending on the race.
  • Evenly distributed covers the whole scalp (No evidences of Alopecia)
  • Maybe thick or thin, coarse or smooth.
  • Neither brittle nor dry.

  1. Observe the face for shape.
  2. Inspect for Symmetry.
    • Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes.
    • Ask the patient to smile, There should be bilateral Nasolabial fold (creases extending from the angle of the corner of the mouth). Slight asymmetry in the fold is normal.
    • If both are met, then the Face is symmetrical
  3. Test the functioning of Cranial Nerves that innervates the facial structures
CN V (Trigeminal)

1. Sensory Function

  • Ask the client to close the eyes.
  • Run cotton wisp over the fore head, check and jaw on both sides of the face.
  • Ask the client if he/she feel it, and where she feels it.
  • Check for corneal reflex using cotton wisp.
  • The normal response in blinking.

2. Motor function

  • Ask the client to chew or clench the jaw.
  • The client should be able to clench or chew with strength and force.
CN VII (Facial)

1. Sensory function (This nerve innervate the anterior 2/3 of the tongue).

  • Place a sweet, sour, salty, or bitter substance near the tip of the tongue.
  • Normally, the client can identify the taste.

2. Motor function

  • Ask the client to smile, frown, raise eye brow, close eye lids, whistle, or puff the cheeks.
Normal Findings
  • Shape maybe oval or rounded.
  • Face is symmetrical.
  • No involuntary muscle movements.
  • Can move facial muscles at will.
  • Intact cranial nerve V and VII.
Eyebrows, Eyes and Eyelashes
  • All three structures are assessed using the modality of inspection.
Normal findings


  • Symmetrical and in line with each other.
  • Maybe black, brown or blond depending on race.
  • Evenly distributed.


  • Evenly placed and inline with each other.
  • None protruding.
  • Equal palpebral fissure.


  • Color dependent on race.
  • Evenly distributed.
  • Turned outward.
Eyelids and Lacrimal Apparatus

1. Inspect the eyelids for position and symmetry.

2. Palpate the eyelids for the lacrimal glands.

  1. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim.
  2. Inquire for any pain or tenderness.

3. Palpate for the nasolacrimal duct to check for obstruction.

  1. To assess the nasolacrimal duct, the examiner presses with the index finger against the client’s lower inner orbital rim, at the lacrimal sac, NOT AGAINST THE NOSE.
  2. In the presence of blockage, this will cause regurgitation of fluid in the puncta
Normal Findings


  • Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.
  • No PTOSIS noted. (Drooping of upper eyelids).
  • Meets completely when eyes are closed.
  • Symmetrical.

Lacrimal Apparatus

  • Lacrimal gland is normally non palpable.
  • No tenderness on palpation.
  • No regurgitation from the nasolacrimal duct.
  • The bulbar and palpebral conjunctivae are examined by separating the eyelids widely and having the client look up, down and to each side. When separating the lids, the examiner should exert NO PRESSURE against the eyeball; rather, the examiner should hold the lids against the ridges of the bony orbit surrounding the eye.

In examining the palpebral conjunctiva, everting the upper eyelid in necessary and is done as follow:

  1. Ask the client to look down but keep his eyes slightly open. This relaxes the levator muscles, whereas closing the eyes contracts the orbicularis muscle, preventing lid eversion.
  2. Gently grasp the upper eyelashes and pull gently downward. Do not pull the lashes outward or upward; this, too, causes muscles contraction.
  3. Place a cotton tip application about I can above the lid margin and push gently downward with the applicator while still holding the lashes. This everts the lid.
  4. Hold the lashes of the everted lid against the upper ridge of the bony orbit, just beneath the eyebrow, never pushing against the eyebrow.
  5. Examine the lid for swelling, infection, and presence of foreign objects.
  6. To return the lid to its normal position, move the lid slightly forward and ask the client to look up and to blink. The lid returns easily to its normal position.
Normal Findings:
  • Both conjunctivae are pinkish or red in color.
  • With presence of many minutes capillaries.
  • Moist
  • No ulcers
  • No foreign objects
  • The sclerae is easily inspected during the assessment of the conjunctivae.
Normal Findings
  • Sclerae is white in color (anicteric sclera)
  • No yellowish discoloration (icteric sclera).
  • Some capillaries maybe visible.
  • Some people may have pigmented positions.
  • The cornea is best inspected by directing penlight obliquely from several positions.
Normal findings
  • There should be no irregularities on the surface.
  • Looks smooth.
  • The cornea is clear or transparent. The features of the iris should be fully visible through the cornea.
  • There is a positive corneal reflex.
Anterior Chamber and Iris
  • The anterior chamber and the iris are easily inspected in conjunction with the cornea. The technique of oblique illumination is also useful in assessing the anterior chamber.
Normal Findings:
  • The anterior chamber is transparent.
  • No noted any visible materials.
  • Color of the iris depends on the person’s race (black, blue, brown or green).
  • From the side view, the iris should appear flat and should not be bulging forward. There should be NO crescent shadow casted on the other side when illuminated from one side.
  • Examination of the pupils involves several inspections, including assessment of the size, shape reaction to light is directed is observed for direct response of constriction. Simultaneously, the other eye is observed for consensual response of constriction.

The test for papillary accommodation is the examination for the change in papillary size as it is switched from a distant to a near object.

  • Ask the client to stare at the objects across room.
  • Then ask the client to fix his gaze on the examiner’s index fingers, which is placed 5 – 5 inches from the client’s nose.
  • Visualization of distant objects normally causes papillary dilation and visualization of nearer objects causes papillary constriction and convergence of the eye.
Normal Findings
  • Pupillary size ranges from 3 – 7 mm, and are equal in size.
  • Equally round.
  • Constrict briskly/sluggishly when light is directed to the eye, both directly and consensual.
  • Pupils dilate when looking at distant objects, and constrict when looking at nearer objects.

If all of which are met, we document the findings using the notation PERRLA, pupils equally round, reactive to light, and accommodate

Cranial Nerve II (optic nerve)
  • The optic nerve is assessed by testing for visual acuity and peripheral vision.
  • Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces in different directions, maybe used.
  • The chart has a standardized number at the end of each line of letters; these numbers indicates the degree of visual acuity when measured at a distance of 20 feet.
  • The numerator 20 is the distance in feet between the chart and the client, or the standard testing distance. The denominator 20 is the distance from which the normal eye can read the lettering, which correspond to the number at the end of each letter line; therefore the larger the denominator the poorer the version.
  • Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder.

In testing for visual acuity you may refer to the following:

  • The room used for this test should be well lighted.
  • A person who wears corrective lenses should be tested with and without them to check fro the adequacy of correction.
  • Only one eye should be tested at a time; the other eye should be covered by an opaque card or eye cover, not with client’s finger.
  • Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to smallest or vice versa.
  • A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand movement about 12 inches from their eyes, or if they can perceive the light of the penlight directed to their yes.
Peripheral Vision or visual fields
  • The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a rather gross measurement of peripheral vision.
  • The performance of this test assumes that the examiner has normal visual fields, since that client’s visual fields are to be compared with the examiners.

Follow the steps on conducting the test:

  1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the distance of 1.5 – 2 feet apart.
  2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client covered eye.
  3. Instruct the client to stare directly at the examiner’s eye, while the examiner stares at the client’s open eye. Neither looks out at the object approaching from the periphery.
  4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the periphery of both directions horizontally and from above and below.
  5. Normally the client should see the same time the examiners sees it. The normal visual field is 180 degrees.
Cranial Nerve III, IV & VI (Oculomotor, Trochlear, Abducens)
  • All the 3 Cranial nerves are tested at the same time by assessing the Extra Ocular Movement (EOM) or the six cardinal position of gaze.

Follow the given steps:

  1. Stand directly in front of the client and hold a finger or a penlight about 1 ft from the client’s eyes.
  2. Instruct the client to follow the direction the object hold by the examiner by eye movements only; that is with out moving the neck.
  3. The nurse moves the object in a clockwise direction hexagonally.
  4. Instruct the client to fix his gaze momentarily on the extreme position in each of the six cardinal gazes.
  5. The examiner should watch for any jerky movements of the eye (nystagmus).
  6. Normally the client can hold the position and there should be no nystagmus.
  1. Inspect the auricles of the ears for parallelism, size position, appearance and skin color.
  2. Palpate the auricles and the mastoid process for firmness of the cartilage of the auricles, tenderness when manipulating the auricles and the mastoid process.
  3. Inspect the auditory meatus or the ear canal for color, presence of cerumen, discharges, and foreign bodies.
    • For adult pull the pinna upward and backward to straiten the canal.
    • For children pull the pinna downward and backward to straiten the canal
  4. Perform otoscopic examination of the tympanic membrane, noting the color and landmarks.
Normal Findings
  • The ear lobes are bean shaped, parallel, and symmetrical.
  • The upper connection of the ear lobe is parallel with the outer canthus of the eye.
  • Skin is same in color as in the complexion.
  • No lesions noted on inspection.
  • The auricles are has a firm cartilage on palpation.
  • The pinna recoils when folded.
  • There is no pain or tenderness on the palpation of the auricles and mastoid process.
  • The ear canal has normally some cerumen of inspection.
  • No discharges or lesions noted at the ear canal.
  • On otoscopic examination the tympanic membrane appears flat, translucent and pearly gray in color.
Nose and Paranasal Sinuses
The external portion of the nose is inspected for the following:
  1. Placement and symmetry.
  2. Patency of nares (done by occluding nosetril one at a time, and noting for difficulty in breathing)
  3. Flaring of alae nasi
  4. Discharge
The external nares are palpated for:
  1. Displacement of bone and cartilage.
  2. For tenderness and masses

The internal nares are inspected by hyper extending the neck of the client, the ulnar aspect of the examiners hard over the fore head of the client, and using the thumb to push the tip of the nose upward while shining a light into the nares.

Inspect for the following:
  1. Position of the septum.
  2. Check septum for perforation. (Can also be checked by directing the lighted penlight on the side of the nose, illumination at the other side suggests perforation).
  3. The nasal mucosa (turbinates) for swelling, exudates and change in color.
Paranasal Sinuses
  • Examination of the paranasal sinuses is indirectly. Information about their condition is gained by inspection and palpation of the overlying tissues. Only frontal and maxillary sinuses are accessible for examination.
  • By palpating both cheeks simultaneously, one can determine tenderness of the maxillary sinusitis, and pressing the thumb just below the eyebrows, we can determine tenderness of the frontal sinuses.
Normal Findings
  • Nose in the midline
  • No Discharges.
  • No flaring alae nasi.
  • Both nares are patent.
  • No bone and cartilage deviation noted on palpation.
  • No tenderness noted on palpation.
  • Nasal septum in the mid line and not perforated.
  • The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy).
  • No tenderness noted on palpation of the paranasal sinuses.
Cranial Nerve I (Olfactory Nerve)
To test the adequacy of function of the olfactory nerve:
  1. The client is asked to close his eyes and occlude.
  2. The examiner places aromatic and easily distinguish nose. (E.g. coffee).
  3. Ask the client to identify the odor.
  4. Each side is tested separately, ideally with two different substances.
Mouth and Oropharynx Lips

Inspected for:

  1. Symmetry and surface abnormalities.
  2. Color
  3. Edema

Normal Findings:

  1. With visible margin
  2. Symmetrical in appearance and movement
  3. Pinkish in color
  4. No edema

Palpate while the mouth is opened wide and then closed for:

  1. Crepitous
  2. Deviations
  3. Tenderness

Normal Findings:

  1. Moves smoothly no crepitous.
  2. No deviations noted
  3. No pain or tenderness on palpation and jaw movement.

Inspected for:

  1. Color
  2. Bleeding
  3. Retraction of gums.

Normal Findings:

  1. Pinkish in color
  2. No gum bleeding
  3. No receding gums

Inspected for:

  1. Number
  2. Color
  3. Dental carries
  4. Dental fillings
  5. Alignment and malocclusions (2 teeth in the space for 1, or overlapping teeth).
  6. Tooth loss
  7. Breath should also be assessed during the process.

Normal Findings:

  1. 28 for children and 32 for adults.
  2. White to yellowish in color
  3. With or without dental carries and/or dental fillings.
  4. With or without malocclusions.
  5. No halitosis.

Palpated for:

  1. Texture

Normal Findings:

  1. Pinkish with white taste buds on the surface.
  2. No lesions noted.
  3. No varicosities on ventral surface.
  4. Frenulum is thin attaches to the posterior 1/3 of the ventral aspect of the tongue.
  5. Gag reflex is present.
  6. Able to move the tongue freely and with strength.
  7. Surface of the tongue is rough.

Inspected for:

  1. Position
  2. Color
  3. Cranial Nerve X (Vagus nerve) – Tested by asking the client to say “Ah” note that the uvula will move upward and forward.

Normal Findings:

  1. Positioned in the mid line.
  2. Pinkish to red in color.
  3. No swelling or lesion noted.
  4. Moves upward and backwards when asked to say “ah”

Inspected for:

  1. Inflammation
  2. Size

A Grading system used to describe the size of the tonsils can be used.

  • Grade 1 – Tonsils behind the pillar.
  • Grade 2 – Between pillar and uvula.
  • Grade 3 – Touching the uvula
  • Grade 4 – In the midline.
  • The neck is inspected for position symmetry and obvious lumps visibility of the thyroid gland and Jugular Venous Distension
Normal Findings:
  1. The neck is straight.
  2. No visible mass or lumps.
  3. Symmetrical
  4. No jugular venous distension (suggestive of cardiac congestion).

The neck is palpated just above the suprasternal note using the thumb and the index finger.

Normal Findings:
  1. The trachea is palpable.
  2. It is positioned in the line and straight.
  • Lymph nodes are palpated using palmar tips of the fingers via systemic circular movements. Describe lymph nodes in terms of size, regularity, consistency, tenderness and fixation to surrounding tissues.
Normal Findings:
  • May not be palpable. Maybe normally palpable in thin clients.
  • Non tender if palpable.
  • Firm with smooth rounded surface.
  • Slightly movable.
  • About less than 1 cm in size.
  • The thyroid is initially observed by standing in front of the client and asking the client to swallow. Palpation of the thyroid can be done either by posterior or anterior approach.
Posterior Approach:
  1. Let the client sit on a chair while the examiner stands behind him.
  2. In examining the isthmus of the thyroid, locate the cricoid cartilage and directly below that is the isthmus.
  3. Ask the client to swallow while feeling for any enlargement of the thyroid isthmus.
  4. To facilitate examination of each lobe, the client is asked to turn his head slightly toward the side to be examined to displace the sternocleidomastoid, while the other hand of the examiner pushes the thyroid cartilage towards the side of the thyroid lobe to be examined.
  5. Ask the patient to swallow as the procedure is being done.
  6. The examiner may also palate for thyroid enlargement by placing the thumb deep to and behind the sternocleidomastoid muscle, while the index and middle fingers are placed deep to and in front of the muscle.
  7. Then the procedure is repeated on the other side.
Anterior approach:
  1. The examiner stands in front of the client and with the palmar surface of the middle and index fingers palpates below the cricoid cartilage.
  2. Ask the client to swallow while palpation is being done.
  3. In palpating the lobes of the thyroid, similar procedure is done as in posterior approach. The client is asked to turn his head slightly to one side and then the other of the lobe to be examined.
  4. Again the examiner displaces the thyroid cartilage towards the side of the lobe to be examined.
  5. Again, the examiner palpates the area and hooks thumb and fingers around the sternocleidomastoid muscle.
Normal Findings:
  1. Normally the thyroid is non palpable.
  2. Isthmus maybe visible in a thin neck.
  3. No nodules are palpable.

Auscultation of the Thyroid is necessary when there is thyroid enlargement. The examiner may hear bruits, as a result of increased and turbulence in blood flow in an enlarged thyroid.

  • Check the Range of Movement of the neck.
Thorax (Cardiovascular System)
Inspection of the Heart
  • The chest wall and epigastrum is inspected while the client is in supine position. Observe for pulsation and heaves or lifts
Normal Findings:
  1. Pulsation of the apical impulse maybe visible. (this can give us some indication of the cardiac size).
  2. There should be no lift or heaves.
Palpation of the Heart
  • The entire precordium is palpated methodically using the palms and the fingers, beginning at the apex, moving to the left sternal border, and then to the base of the heart.
Normal Findings:
  1. No, palpable pulsation over the aortic, pulmonic, and mitral valves.
  2. Apical pulsation can be felt on palpation.
  3. There should be no noted abnormal heaves, and thrills felt over the apex.
Percussion of the Heart
  • The technique of percussion is of limited value in cardiac assessment. It can be used to determine borders of cardiac dullness.
Auscultation of the Heart

Anatomic areas for auscultation of the heart:

  • Aortic valve – Right 2nd ICS sternal border.
  • Pulmonic Valve – Left 2nd ICS sternal border.
  • Tricuspid Valve – – Left 5th ICS sternal border.
  • Mitral Valve – Left 5th ICS midclavicular line

Positioning the client for auscultation:

  • If the heart sounds are faint or undetectable, try listening to them with the patient seated and learning forward, or lying on his left side, which brings the heart closer to the surface of the chest.
  • Having the client seated and learning forward s best suited for hearing high-pitched sounds related to semilunar valves problem.
  • The left lateral recumbent position is best suited low-pitched sounds, such as mitral valve problems and extra heart sounds.

Auscultating the heart:

  1. Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid and mitral
  2. Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure of semilunar valve). S1 sound is best heard over the mitral valve; S2 is best heard over the aortric valve.
  3. Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.
  4. Count heart rate at the apical pulse for one full minute.

Normal Findings:

  1. S1 & S2 can be heard at all anatomic site.
  2. No abnormal heart sounds is heard (e.g. Murmurs, S3 & S4).
  3. Cardiac rate ranges from 60 – 100 bpm.
Inspection of the Breast

There are 4 major sitting position of the client used for clinical breast examination. Every client should be examined in each position.

  1. The client is seated with her arms on her side.
  2. The client is seated with her arms abducted over the head.
  3. The client is seated and is pushing her hands into her hips, simultaneously eliciting contraction of the pectoral muscles.
  4. The client is seated and is learning over while the examiner assists in supporting and balancing her.
  • While the client is performing these maneuvers, the breasts are carefully observed for symmetry, bulging, retraction, and fixation.
  • An abnormality may not be apparent in the breasts at rest a mass may cause the breasts, through invasion of the suspensory ligaments, to fix, preventing them from upward movement in position 2 and 4.
  • Position 3 specifically assists in eliciting dimpling if a mass has infiltrated and shortened suspensory ligaments.
Normal Findings:
  1. The overlying the breast should be even.
  2. May or may not be completely symmetrical at rest.
  3. The areola is rounded or oval, with same color, (Color va,ies form light pink to dark brown depending on race).
  4. Nipples are rounded, everted, same size and equal in color.
  5. No “orange peel” skin is noted which is present in edema.
  6. The veins maybe visible but not engorge and prominent.
  7. No obvious mass noted.
  8. Not fixated and moves bilaterally when hands are abducted over the head, or is learning forward.
  9. No retractions or dimpling.
Palpation of the Breast
  • Palpate the breast along imaginary concentric circles, following a clockwise rotary motion, from the periphery to the center going to the nipples. Be sure that the breast is adequately surveyed. Breast examination is best done 1 week post menses.
  • Each areolar areas are carefully palpated to determine the presence of underlying masses.
  • Each nipple is gently compressed to assess for the presence of masses or discharge.
Normal Findings:
  • No lumps or masses are palpable.
  • No tenderness upon palpation.
  • No discharges from the nipples.

NOTE: The male breasts are observed by adapting the techniques used for female clients. However, the various sitting position used for woman is unnecessary.

  • In abdominal assessment, be sure that the client has emptied the bladder for comfort. Place the client in a supine position with the knees slightly flexed to relax abdominal muscles.
Inspection of the abdomen
  • Inspect for skin integrity (Pigmentation, lesions, striae, scars, veins, and umbilicus).
  • Contour (flat, rounded, scapold)
  • Distension
  • Respiratory movement.
  • Visible peristalsis.
  • Pulsations
Normal Findings:
  • Skin color is uniform, no lesions.
  • Some clients may have striae or scar.
  • No venous engorgement.
  • Contour may be flat, rounded or scapoid
  • Thin clients may have visible peristalsis.
  • Aortic pulsation maybe visible on thin clients.
Auscultation of the Abdomen
  • This method precedes percussion because bowel motility, and thus bowel sounds, may be increased by palpation or percussion.
  • The stethoscope and the hands should be warmed; if they are cold, they may initiate contraction of the abdominal muscles.
  • Light pressure on the stethoscope is sufficient to detect bowel sounds and bruits. Intestinal sounds are relatively high-pitched, the bell may be used in exploring arterial murmurs and venous hum.
Peristaltic sounds
  • These sounds are produced by the movements of air and fluids through the gastrointestinal tract. Peristalsis can provide diagnostic clues relevant to the motility of bowel.

Listening to the bowel sounds (borborygmi) can be facilitated by following these steps:

  1. Divide the abdomen in four quadrants.
  2. Listen over all auscultation sites, starting at the right lower quadrants, following the cross pattern of the imaginary lines in creating the abdominal quadrants. This direction ensures that we follow the direction of bowel movement.
  3. Peristaltic sounds are quite irregular. Thus it is recommended that the examiner listen for at least 5 minutes, especially at the periumbilical area, before concluding that no bowel sounds are present.
  4. The normal bowel sounds are high-pitched, gurgling noises that occur approximately every 5 – 15 seconds. It is suggested that the number of bowel sound may be as low as 3 to as high as 20 per minute, or roughly, one bowel sound for each breath sound.

Some factors that affect bowel sound:

  1. Presence of food in the GI tract.
  2. State of digestion.
  3. Pathologic conditions of the bowel (inflammation, Gangrene, paralytic ileus, peritonitis).
  4. Bowel surgery
  5. Constipation or Diarrhea.
  6. Electrolyte imbalances.
  7. Bowel obstruction.
Percussion of the abdomen
  • Abdominal percussion is aimed at detecting fluid in the peritoneum (ascites), gaseous distension, and masses, and in assessing solid structures within the abdomen.
  • The direction of abdominal percussion follows the auscultation site at each abdominal guardant.
  • The entire abdomen should be percussed lightly or a general picture of the areas of tympany and dullness.
  • Tympany will predominate because of the presence of gas in the small and large bowel. Solid masses will percuss as dull, such as liver in the RUQ, spleen at the 6th or 9th rib just posterior to or at the mid axillary line on the left side.
  • Percussion in the abdomen can also be used in assessing the liver span and size of the spleen.
Percussion of the liver

The palms of the left hand are placed over the region of liver dullness.

  1. The area is strucked lightly with a fisted right hand.
  2. Normally tenderness should not be elicited by this method.
  3. Tenderness elicited by this method is usually a result of hepatitis or cholecystitis.
Renal Percussion
  1. Can be done by either indirect or direct method.
  2. Percussion is done over the costovertebral junction.
  3. Tenderness elicited by such method suggests renal inflammation.
Palpation of the Abdomen

Light palpation

  • It is a gentle exploration performed while the client is in supine position. With the examiner’s hands parallel to the floor.
  • The fingers depress the abdominal wall, at each quadrant, by approximately 1 cm without digging, but gently palpating with slow circular motion.
  • This method is used for eliciting slight tenderness, large masses, and muscles, and muscle guarding.

Tensing of abdominal musculature may occur because of:

  1. The examiner’s hands are too cold or are pressed to vigorously or deep into the abdomen.
  2. The client is ticklish or guards involuntarily.
  3. Presence of subjacent pathologic condition.

Normal Findings:

  1. No tenderness noted.
  2. With smooth and consistent tension.
  3. No muscles guarding.

Deep Palpation

  • It is the indentation of the abdomen performed by pressing the distal half of the palmar surfaces of the fingers into the abdominal wall.
  • The abdominal wall may slide back and forth while the fingers move back and forth over the organ being examined.
  • Deeper structures, like the liver, and retro peritoneal organs, like the kidneys, or masses may be felt with this method.
  • In the absence of disease, pressure produced by deep palpation may produce tenderness over the cecum, the sigmoid colon, and the aorta.
Liver palpation

There are two types of bi manual palpation recommended for palpation of the liver. The first one is the superimposition of the right hand over the left hand.

  1. Ask the patient to take 3 normal breaths.
  2. Then ask the client to breath deeply and hold. This would push the liver down to facilitate palpation.
  3. Press hand deeply over the RUQ

The second methods:

  1. The examiner’s left hand is placed beneath the client at the level of the right 11th and 12th ribs.
  2. Place the examiner’s right hands parallel to the costal margin or the RUQ.
  3. An upward pressure is placed beneath the client to push the liver towards the examining right hand, while the right hand is pressing into the abdominal wall.
  4. Ask the client to breath deeply.
  5. As the client inspires, the liver maybe felt to slip beneath the examining fingers.

Normal Findings:

  • The liver usually can not be palpated in a normal adult. However, in extremely thin but otherwise well individuals, it may be felt the costal margins.
  • When the normal liver margin is palpated, it must be smooth, regular in contour, firm and non-tender.
  1. Observe for size, contour, bilateral symmetry, and involuntary movement.
  2. Look for gross deformities, edema, presence of trauma such as ecchymosis or other discoloration.
  3. Always compare both extremities.
  1. Feel for evenness of temperature. Normally it should be even for all the extremities.
  2. Tonicity of muscle. (Can be measured by asking client to squeeze examiner’s fingers and noting for equality of contraction).
  3. Perform range of motion.
  4. Test for muscle strength. (performed against gravity and against resistance)

Table showing the Lovett scale for grading for muscle strength and functional level

Functional level Lovett Scale Grade Percentage of normal
No evidence of contractility Zero (Z) 0 0
Evidence of slight contractility Trace (T) 1 10
Complete ROM without gravity Poor (P) 2 25
Complete ROM with gravity Fair (F) 3 50
Complete range of motion against gravity with some resistance Good (G) 4 75
Complete Your browser may not support display of this image. range of motion against gravity with full resistance Normal (N) 5 100
Normal Findings
  • Both extremities are equal in size.
  • Have the same contour with prominences of joints.
  • No involuntary movements.
  • No edema
  • Color is even.
  • Temperature is warm and even.
  • Has equal contraction and even.
  • Can perform complete range of motion.
  • No crepitus must be noted on joints.
  • Can counter act gravity and resistance on ROM.


Welcome to your Head to Toe Assessment! This exam is carefully curated to help you consolidate your knowledge and gain deeper understanding on the topic.


Exam Details

  • Number of Questions: 35 items
  • Mode: Practice Mode

Exam Instructions

  1. Practice Mode: This mode aims to facilitate effective learning and review.
  2. Instant Feedback: After each question, the correct answer along with an explanation will be revealed. This is to help you understand the reasoning behind the correct answer, helping to reinforce your learning.
  3. Time Limit: There is no time limit for this exam. Take your time to understand each question and the corresponding choices.

Tips For Success

  • Read each question carefully. Take your time and don't rush.
  • Understand the rationale behind each answer. This will not only help you during this exam, but also assist in reinforcing your learning.
  • Don't be discouraged by incorrect answers. Use them as an opportunity to learn and improve.
  • Take breaks if you need them. It's not a race, and your understanding is what's most important.
  • Keep a positive attitude and believe in your ability to succeed.

Remember, this exam is not just a test of your knowledge, but also an opportunity to enhance your understanding and skills. Enjoy the learning journey!


Click 'Start Exam' when you're ready to begin. Best of luck!

💡 Hint

The specific cranial nerve being tested in vision assessments is responsible for transmitting visual information from the eye to the brain. Consider which nerve would be directly involved in the perception of sight.

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1. Nurse Mitchell is performing an assessment on a client's vision utilizing either the Snellen chart or the newspaper finger-wiggle test. By conducting this assessment, Nurse Mitchell is primarily evaluating the function of which cranial nerve?

💡 Hint

An ophthalmoscope is a vital tool used by medical professionals to visualize the back part of the eyeball, including the retina. Think about what can be seen by looking through this area, and you'll find the correct use.

2 / 35

2. Nurse Miller is in the process of conducting a thorough eye examination on an elderly patient complaining of blurred vision. She decides to utilize an ophthalmoscope as part of her assessment. What is the primary purpose of using an ophthalmoscope in this situation?

💡 Hint

Hand hygiene is vital in healthcare for infection control, and it also builds trust and confidence in care. Consider what would be the most transparent action that emphasizes safety and professionalism in front of the client.

3 / 35

3. In the context of hand hygiene during nursing care, what action should always be taken with regard to your client?

💡 Hint

The red light reflex is commonly examined as part of an ocular assessment. The normal finding should be consistent with what one would expect when light reflects off the inner surface of the eye.

4 / 35

4. During a routine eye examination on a middle-aged patient, Nurse Thompson is using an ophthalmoscope to evaluate the red light reflex. In this context, what would be regarded as a customary observation regarding the patient's red light reflex?

💡 Hint

In assessing a client's physical appearance, a nurse examines observable characteristics related to health. Consider what would be visually and audibly apparent and relevant.

5 / 35

5. During a client's assessment, Nurse Patterson is carefully evaluating the physical appearance as part of the overall examination. Which of the following selections accurately outlines what a nurse would typically look for during this aspect of the assessment?

💡 Hint

Focus on the reflex that tests a natural and immediate reaction to a light touch on the surface of the eye. It’s a common assessment performed on the eyes during a neurological examination.

6 / 35

6. While examining his client's eyes, Nurse Franco uses a light cotton ball and gently brushes it across his client's eyes to elicit a blink. What specific test or reflex is Nurse Franco performing through this action?

💡 Hint

In a head-to-toe examination, the assessment begins by observing the overall state of the patient. Think about what provides the broadest view of the patient's condition before focusing on specific areas.

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7. When initiating a comprehensive head-to-toe examination, what is the very first thing a nurse will assess?

💡 Hint

When a patient reports pain, the initial step should focus on understanding the intensity and nature of the pain. Consider the standard scale used in clinical practice to quantify pain.

8 / 35

8. A patient in the post-surgical unit informs Nurse Johnson that they are experiencing pain. Understanding the urgency of addressing this complaint, what would Nurse Johnson do first?

💡 Hint

Among the listed options, one is a specific condition that is not typically considered a standard change associated with aging or normal variation. Focus on what might be considered an abnormal finding in a general population.

9 / 35

9. When assessing the scalp and hair of a middle-aged man, which of the following would not be considered normal findings?

💡 Hint

Consider the cranial nerve responsible for sensations in the face, including the cornea of the eye. This nerve allows the body to respond to touch stimuli on the face and is typically assessed through the corneal reflex test.

10 / 35

10. While conducting an eye examination, a nurse decides to perform a corneal reflex test. By carrying out this specific evaluation, which cranial nerve is the nurse primarily assessing?

💡 Hint

Think about the essential protocols and practices that must be followed in nursing care to maintain safety and infection control before any physical contact with the patient.

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11. Before initiating the palpation of a person's scalp during a head-to-toe examination, what is the very first action a nurse should take?

💡 Hint

Consider the cranial nerve responsible for controlling most facial expressions and taste sensations. The movements Nurse Bill is asking his client to perform directly relate to this nerve's functions.

12 / 35

12. During a comprehensive head-to-toe assessment, Nurse Bill instructs his client to perform a series of facial movements including smiling, frowning, wrinkling the forehead, puffing the cheeks, raising the eyebrows, and closing the eyelids. Through these specific actions, which cranial nerve is Nurse Bill most likely assessing?

💡 Hint

Focus on what the movement and walking style of the client can reveal about their physical condition. Consider what aspects of the client's health can be directly inferred from their way of walking.

13 / 35

13. As the client walks into the examination room, what would the nurse be able to assess based solely on the way the client moves?

💡 Hint

The specific action of wiggling a finger out to the side while the client's eyes are fixed on a point helps to assess a particular area of vision. Consider what part of the visual field is being tested with this maneuver.

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14. During an eye examination, Nurse Adams has the client read a newspaper and then wiggles her finger out to the side, instructing the client to report when the finger is seen without moving their eyes. Through this test, what specific aspect of the client's eye function is Nurse Adams most likely assessing?

💡 Hint

Focus on the joint that allows the jaw to move in activities such as chewing and speaking. Nurse Joan's instruction to clench the jaw would provide insight into the function and condition of this specific joint.

15 / 35

15. As Nurse Joan continues her assessment of her patient Freedy, she pays special attention to his head, particularly the jaw area. She instructs Freedy to clench his jaw as she places her fingers near the side of his face, attempting to evaluate a specific joint. When Nurse Joan asks Freedy to clench his jaw and palpates the side of his face, what joint is she most likely trying to assess?

💡 Hint

The assessment of physical appearance mainly involves observing visible characteristics and features. Think about which option includes an action that would be part of a different type of assessment, not solely related to appearance.

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16. During the observation of a client's physical appearance, a nurse would typically assess various characteristics. Which of the following would NOT typically be included in the initial assessment of a client's physical appearance?

💡 Hint

When evaluating a patient's speech as part of a normal neurological assessment, the nurse looks for clarity and coherence. Abnormal speech patterns could indicate underlying issues, but the correct answer refers to what is expected in normal, healthy communication.

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17. Nurse Thompson is conducting a neurological examination for a client who recently suffered a minor stroke. She is keenly observing the client's speech during their conversation. Which of the following would be considered normal observations regarding the client's speech?

💡 Hint

Think about the cranial nerve responsible for sensation in the face and motor functions, such as biting and chewing. This particular assessment technique targets that nerve.

18 / 35

18. While performing a cranial nerve assessment on a patient, a nurse gently palpates the temporomandibular joint and then instructs the patient to clench his teeth. By engaging in this particular evaluation, the nurse is most likely attempting to assess the function of which specific cranial nerve?

💡 Hint

Nurse Dave's questions are aiming to evaluate the client's alertness and orientation to time, place, and person. This isn't directly related to social interaction or overall intelligence but rather to a specific mental state.

19 / 35

19. During a routine assessment at the geriatric care unit, Nurse Dave approaches his elderly client. He gently asks for the client's name, date of birth, whether he knows where he is, and what day of the week it is. Through these questions, Nurse Dave is primarily assessing his client's what?

💡 Hint

Before delving into more detailed examinations such as pupil reaction or internal structures, the initial observation should be directed towards the visible, outer parts of the eyes. This forms the basis for the eye examination.

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20. During an assessment focusing on a client's eyes, what should be the very first aspect a nurse should observe?

💡 Hint

The action of reading from a chart at a specific distance while one eye is blocked is a classic method used to gauge a certain sense. Think about what sense is being tested through this particular procedure.

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21. During a comprehensive head-to-toe assessment, Nurse Williams has his client stand 20 feet away from a chart. While blocking one eye, he asks the client to read the smallest line he can and repeats the procedure with the other eye. In this scenario, what is Nurse Williams most likely evaluating in his client?

💡 Hint

When assessing the general appearance during the greeting, the nurse will be considering signs of comfort, approachability, and positive engagement. Consider what a healthy and normal interaction would look like.

22 / 35

22. Nurse Adams is starting the assessment of a new patient in the primary care clinic. As part of the initial interaction, Nurse Adams pays close attention to the patient's greeting. Which of the following would be included as normal observations regarding the client’s greeting in the general appearance portion of the assessment?

💡 Hint

In palpating an artery, the force is usually graded on a scale of 0 to +4. Think about what rating would indicate a normal, healthy pulse strength.

23 / 35

23. When assessing the force of a temporal artery, which of the following would a nurse consider to be a normal observation?

💡 Hint

Consider what observations are typically made during the general appearance part of the assessment. The answer will reflect what the nurse has been focusing on and needs to document at the conclusion of this section.

24 / 35

24. As Nurse Harris concludes the general appearance portion of the head-to-toe assessment for a patient in the outpatient department, she prepares to transition to the next phase. Which two things would Nurse Harris state she is going to do at the end of the general appearance portion of the assessment?

💡 Hint

When palpating an artery such as the temporal artery, consider what specific characteristic of the pulse is most relevant and should be noted as part of a standard assessment.

25 / 35

25. While palpating the client's temporal artery during a physical assessment, what essential aspect should a nurse remember to document?

💡 Hint

When conducting an assessment on the client's head, the nurse starts by examining key features. Think about what area should be observed and palpated first to gain an understanding of the client's head condition.

26 / 35

26. Nurse Taylor is initiating an assessment of a client's head as part of a comprehensive examination. What would be the first action Nurse Taylor should take in this assessment?

💡 Hint

Consider the cranial nerves involved in speech and swallowing functions. They control muscles necessary for speech production and other vital aspects of articulation.

27 / 35

27. While caring for a patient recovering from a stroke, Nurse Anderson is focused on evaluating the patient's ability to speak and articulate words clearly. He carefully assesses the patient's articulation, language, and other aspects of speech. By performing this evaluation, which cranial nerves has Nurse George most likely assessed?

💡 Hint

When palpating the sinuses, the nurse's main concern is to detect a common symptom that might indicate an underlying issue such as a sinus infection. This could manifest as discomfort in the specific areas being examined.

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28. During an assessment, a nurse carefully palpates a client's frontal and maxillary sinuses. In this specific evaluation, what is the nurse primarily focusing on to ensure a comprehensive assessment?

💡 Hint

The initial evaluation of the eyes' external structures usually includes an examination of the physical features and any visible signs that might indicate underlying problems, such as infection or other abnormalities.

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29. When conducting an examination focused on the external structures of the eyes, what are the three primary aspects a nurse needs to check for?

💡 Hint

When assessing the scalp, a nurse focuses on medical aspects that might indicate a health issue. Think about what would be relevant to understanding the patient's health, and what might be considered more cosmetic and less relevant in a clinical setting.

30 / 35

30. Nurse Rhian is assessing his client's scalp. After donning clean gloves, he begins to palpate the hair. Which of the following aspects would he NOT typically be looking for during this assessment?

💡 Hint

In a healthcare setting, the observation of clothing isn't about fashion or societal status. Consider what might be important in terms of health, safety, and overall well-being, taking into account the patient's age and other relevant factors.

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31. Nurse Becky is conducting an assessment, and part of her observation includes analyzing the way her client is dressed. As a healthcare professional, what specific aspect is she most likely looking for regarding the client's attire?

💡 Hint

Consider the tools mentioned and what they are commonly used for in a typical examination. The Snellen chart, in particular, is a standard tool in assessing a specific sense that involves letters or symbols.

32 / 35

32. During a routine health check-up, Nurse Johnson is preparing to assess a client's specific sensory function. She has the option to use either a Snellen chart or the finger wiggle test. What aspect of the client's health is Nurse Johnson planning to evaluate?

💡 Hint

In a patient-centered approach, what would be the primary action to establish trust and rapport between the nurse and the patient before any assessment or procedure?

33 / 35

33. Nurse Mitchell is about to start a comprehensive head-to-toe assessment on a new patient. Before delving into the assessment, what is the most fundamental step she should take?

💡 Hint

When assessing a patient's level of consciousness, consider evaluating their orientation to three main aspects: time, place, and person. This provides a comprehensive understanding of their mental awareness and orientation.

34 / 35

34. Nurse Johnson is performing an initial assessment on a patient who has just been admitted to the neurological unit following a head injury. To ensure the client is oriented, she needs to assess the client's level of consciousness. Which of the following will Nurse Johnson check?

💡 Hint

Consider the holistic view that a nurse takes when assessing a patient's general appearance. All aspects, such as nutrition, attire, grooming, and the absence of visible illness, are integral to a comprehensive observation.

35 / 35

35. Nurse Martinez is in the process of evaluating a patient during a routine health screening. Her observations encompass several aspects of the patient's general appearance. Which among the following constitutes standard nursing observations regarding the patient's overall presentation?