Head-To-Toe Assessment (Part 1)

A. Head (Skull, Scalp, Hair)

1. Observe the size, shape and contour of the skull.
2. Observe scalp in several areas by separating the hair at various locations; inquire about any injuries. Note presence of lice, nits, dandruff or lesions.
3. 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)
4. Observe and feel the hair condition.

Normal Findings:

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

Scalp

· 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 nor masses on palpation.

Hair

· 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.

B. Face

1. Observe the face for shape.
2. Inspect for Symmetry.

a. Inspect for the palpebral fissure (distance between the eye lids); should be equal in both eyes.
b. 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.
c. If both are met, then the Face is symmetrical

3. Test the functioning of Cranial Nerves that innervates the facial structures

a. 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.

b. 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.

C. Eyebrows, Eyes and Eyelashes

All three structures are assessed using the modality of inspection.

Normal findings:
Eyebrows
· Symmetrical and in line with each other.
· Maybe black, brown or blond depending on race.
· Evenly distributed.

Eyes
· Evenly placed and inline with each other.
· Non protruding.
· Equal palpebral fissure.

Eyelashes
· Color dependent on race.
· Evenly distributed.
· Turned outward.

All three structures are assessed using the modality of inspection.

Normal findings:

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

Eyes
· Evenly placed and inline with each other.
· Non protruding.
· Equal palpebral fissure.

Eyelashes
· Color dependent on race.
· Evenly distributed.
· Turned outward.

D. Eye lids and Lacrimal Apparatus

1. Inspect the eyelids for position and symmetry.
2. Palpate the eyelids for the lacrimal glands.
a. To examine the lacrimal gland, the examiner, lightly slide the pad of the index finger against the client’s upper orbital rim.
b. Inquire for any pain or tenderness.
3. Palpate for the nasolacrimal duct to check for obstruction.
a. 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.
b. In the presence of blockage, this will cause regurgitation of fluid in the puncta

Normal Findings:

Eyelids

· 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.

E. Conjuctivae

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 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

F. Sclerae

The sclarae is easily inspected during the assessment of the conjunctivae.

Normal Findings:

· Sclarae is white in color (anicteric sclera)
· No yellowish discoloration (icteric sclera).
· Some capillaries maybe visible.
· Some people may have pigmented positions.
G. Cornea

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.

H. 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.

I. Pupils

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 the is switched from a distant to a near object.

1. Ask the client to stare at the objects across room.
2. 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.
3. 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

J. 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:

1. The room used for this test should be well lighted.
2. A person who wears corrective lenses should be tested with and without them to check fro the adequacy of correction.
3. 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.
4. Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to smallest or vice versa.
5. 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 degress.

Daisy Jane Antipuesto RN MN

Currently a Nursing Local Board Examination Reviewer. Subjects handled are Pediatric, Obstetric and Psychiatric Nursing. Previous work experiences include: Clinical instructor/lecturer, clinical coordinator (Level II), caregiver instructor/lecturer, NC2 examination reviewer and staff/clinic nurse. Areas of specialization: Emergency room, Orthopedic Ward and Delivery Room. Also an IELTS passer.

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