Amanda Smith Nurs 320 Unit 7 Head to Toe Assessment

Added: 2026-05-10

[00:00:00]Go.

[00:00:02]>> Hello, my name is Amanda and today I will be performing a focused headto toe physical assessment. This assessment will include inspection, palpation, and oscultation. I will explain each step as I go, demonstrating both technique and clinical reasoning. Before beginning, I am performing hand hygiene.

[00:00:23]Can you confirm your age and that you consent to this assessment and recording? I am 18 and I consent to this assessment and recorded.

[00:00:33]>> Thank you.

[00:00:35]I will ensure your privacy and comfort throughout the exam. Please let me know if anything causes discomfort or if you need to reposition at any time. I have ensured adequate lighting, appropriate equipment and proper positioning so that the assessment can be performed accurately.

[00:00:55]I am beginning with a general survey. I am observing the patients overall appearance, hygiene, posture, and level of consciousness as well as noting any signs of distress or discomfort.

[00:01:10]I am also assessing whether the patient appears their stated age, is alert and oriented, and is interacting appropriately.

[00:01:20]Normal findings include an alert and oriented individual with appropriate hygiene and no acute distress. Abnormal findings could include altered mental status, poor hygiene, labored breathing or visible discomfort which may indicate underlying physical or psychological conditions. So I will start by inspecting the scalp and hair for distribution lesions or abnormalities and palpating the scalp for tenderness or masses.

[00:01:55]I didn't see anything when I was inspecting for distribution any abnormalities.

[00:02:03]I'm sorry. Does that tickle?

[00:02:06]>> Did you feel any discomfort?

[00:02:08]>> No. I did not feel any masses or lesions at this time. Now I'm going to >> put it up.

[00:02:18]>> Yes, if you could put your hair up.

[00:02:28]And just for this part of the assessment, could you remove your glasses?

[00:02:34]Okay.

[00:02:36]I am palpating the temporal arteries for tenderness or thickening s it such as temporal arteritis.

[00:02:45]Now I will assess the temporal mandibular joint at by asking the patient would you open open all the way. Now close open again and close.

[00:03:02]Did that cause you any pain? No. Okay.

[00:03:08]Now I am observing facial symmetry at rest and with movement which would reflect cranial nerve number seven's function.

[00:03:17]Can you at appearance everything looks symmetrical at rest? Can you raise your eyebrows for me and close your eyes real tight?

[00:03:33]Can you smile?

[00:03:35]Can you show me show me your teeth?

[00:03:38]Can you puff up your cheeks?

[00:03:43]Now make a pucker.

[00:03:46]Okay. Everything looked uh symmetrical, smooth. Did any of that cause you pain or discomfort?

[00:03:55]Normal findings include smooth, symmetrical movement and no tenderness?

[00:04:00]Abnormal findings such as asymmetric Asymmetry, drooping or weakness may indicate neurological deficits such as stroke or nerve damage. You can put your glasses back on now.

[00:04:15]Oh, I'm sorry. One more time.

[00:04:20]Okay.

[00:04:21]Now I'm inspecting the outside of the eye structure, the conjunctiva and the scara for redness, lesions or discoloration such as jaundice or palar.

[00:04:33]And jaundice would be yellowing.

[00:04:38]And now could you look back here at my eye? Now I will assess the pupils for equality, roundness, and reaction to light and accommodation.

[00:04:52]Now look at this one.

[00:04:56]And the pupils are equal react or round and react to light and accommodation.

[00:05:07]Now I will test the extraocular movement using the six cardinal fields of gaze to evaluate cranial nerves three, four and six.

[00:05:19]So, as I What am I doing? There we go.

[00:05:23]As I hold my pin light up, I just want you to follow it with just your eyes, keeping your head straight towards me, and just follow it with your eyes and she was able to do that.

[00:05:44]Uh now I will assess visual fields using confrontation to evaluate cranial nerve number two.

[00:05:52]For this one you will have to place your glasses back on.

[00:06:00]Can you cover your right eye with your hand?

[00:06:05]Okay. So I am going to hold my fingers up and I want you to tell me how many fingers I'm holding up at each location that I am holding them. Okay.

[00:06:15]>> Five, two, two, three.

[00:06:21]>> Okay. Now cover the left eye.

[00:06:24]5 2 3 4.

[00:06:29]>> Okay.

[00:06:31]Good job.

[00:06:33]Uh so normal findings for this assessment would include pla which is pupils equal round and reactive to light and accommodation intact visual fields and smooth coordinated eye movements.

[00:06:45]Abnormal findings such as unequal pupils sluggish reaction or limited movement may indicate neurological dysfunction or increased intraanial pressure.

[00:06:57]Now I will inspect and palpate the external ears for lesions, deformities or tenderness.

[00:07:09]Could you turn this way for me?

[00:07:17]Does anything does that hurt at all?

[00:07:26]And how about this side?

[00:07:28]>> No. Okay.

[00:07:34]Now I will assess hearing acuity using a whisper test to evaluate cranial nerve number eight.

[00:07:43]Can you cover your right ear for me?

[00:07:47]I I'm sorry. On cover.

[00:07:50]When I ask you to cover your ear, I want I am going to whisper a three-digit phrase, I just want you, it's a number or letter combination. I just want you to repeat what I whisper.

[00:08:07]>> Can you cover your right ear?

[00:08:10]>> 4 K 2 K.

[00:08:14]>> Now, can you cover your left ear?

[00:08:17]Three. Four. B.

[00:08:21]>> Good job.

[00:08:23]Normal findings include intact hearing bilaterally. Abnormal findings may indicate conductive or sensor neural hearing loss.

[00:08:35]Now I will inspect the external nose and internal nasal passages for symmetry, septal alignment and any signs of obstruction or inflammation.

[00:08:48]Uh, so I don't see any signs of obstruction or any signs of inflammation on the outside. Could you raise your head for me?

[00:08:58]No sign of obstruction in the nasal passage.

[00:09:05]Um, now could you hold your right side like close it off and breathe?

[00:09:15]Now the other side and breathe. Good job.

[00:09:22]I am I will now palpate the frontal and maxillary sinuses for tenderness. For this one, I'll need you to remove your glasses again.

[00:09:33]Look straight at me and let me know if the my touching causes any discomfort.

[00:09:42]Any discomfort? Okay.

[00:09:50]Normal findings include patent nes and no sinus tenderness. Abnormal findings such as tenderness or congestion may indicate sinusitis or infection.

[00:10:01]Now I will inspect the lips, mucosa, gums, teeth, tongue, and the floor of the mouth for color, moisture, lesions, or abnormalities.

[00:10:12]First, I'm just going to look. So, if you can open your mouth.

[00:10:19]Okay. Now, can you stick out your tongue and say ah a >> Can you raise your tongue all the way to the roof of your mouth?

[00:10:31]And can you stick your tongue out?

[00:10:34]Can you move it side to side?

[00:10:38]Okay.

[00:10:41]I was also observed the uvula as the patient said all assessing cranial nerve number 10 for proper elevation. I assess the tongue movement and strength which reflects cranial nerve number 12.

[00:10:58]Normal findings include pink moist mucosa, a midline u uvula and smooth tongue movement. Abnormal findings such as lesions, dryness or deviation may indicate infection, dehydration or neur neurological dysfunction.

[00:11:15]Now I will inspect the neck for symmetry and visible masses which I don't see. I am palpating I will palpate the lymph nodes in a systemic sequence noting at the time size, consistency, mobility and tenderness.

[00:11:34]I'm just going to run my hands down your neck.

[00:11:40]Do you feel any pain or discomfort with that?

[00:11:46]I also assessed the tracheal alignment to ensure that her trachea was midline at the same time.

[00:11:56]Now I will test range of motion and muscle strength by asking the patient to rotate, flex, and extend the neck and shrug shoulders against resistant against resistance to assess cranial nerve number 11. Can you lower your neck all the chin to your chest?

[00:12:18]And then can you look all the way up at the ceiling as far as you can?

[00:12:23]Can you turn to one side and then to the other?

[00:12:29]And can you bend this way and then this way? Good job. And then don't let me push your shoulders down.

[00:12:39]Good job.

[00:12:43]Now I will p I'm sorry. I'm going to touch your neck again. Now I will palpate the thyroid gland for shape and nodules.

[00:12:54]Normal findings include no lymph node enlargement and a midline trachea.

[00:12:59]Enlarged lymph nodes may indicate infection or malignancy and thyroid enlargement may suggest endocrine disorders.

[00:13:07]Now I will inspect the chest for symmetry, respiratory effort and use of accessory muscles.

[00:13:20]And now I will palpate the chest for expansion and tactile fitus comparing bilaterally and oscultating lung sounds in all anterior and posterior fields comparing side to side for consistency.

[00:13:36]So, I'm just going to run my hands down your chest, any discomfort.

[00:13:49]Okay.

[00:13:51]Now, I'm just going to listen to your lung sounds in the front and the back.

[00:13:56]So, if you could just breathe when I ask you to breathe.

[00:14:06]Deep breath.

[00:14:10]Deep breath.

[00:14:13]Deep breath.

[00:14:16]Deep breath.

[00:14:20]Deep breath.

[00:14:23]Deep breath.

[00:14:27]Could you turn this way for me? Just slightly more.

[00:14:44]Okay.

[00:14:46]Deep breath.

[00:14:49]Deep breath again.

[00:14:55]Again.

[00:14:57]And again and again.

[00:15:02]Again.

[00:15:07]Okay.

[00:15:09]Did any of that cause you pain or discomfort while you were taking the big deep breaths?

[00:15:13]>> No. Have you had any shortness of breath, trouble breathing, cough, or any issues like that in the past or past couple weeks? No. Okay. Normal findings include clear equal breast sounds bilaterally. Abnormal findings such as crackles, wheezes, or diminished sounds may indicate conditions such as pneumonia, asthma or fluid accumulation.

[00:15:39]Now I will inspect for jugular vein distension which can indicate fluid overload or heart failure which I would do by looking turn for me right here at this side of the neck to see if there was a pulsating sensation which there is not.

[00:16:01]Now I will palpate the corateed pulses one side at a time to assess strength and symmetry. So, I'm just going to place my hands on your neck again.

[00:16:15]And the other side.

[00:16:21]Okay.

[00:16:25]Now I will oscultate the heart sounds at all valve locations using both the diaphragm or the big side and the bell or the small side to assess for high and low pitch sounds.

[00:16:42]Just going to listen again. You don't have to breathe any special way. Just breathe normally. I'm just listening to your heart sounds.

[00:17:39]Thank you.

[00:18:05]So frustrating. Thank you.

[00:18:13]Okay. Normal findings include distinct S1 and S2 sounds with a regular rhythm.

[00:18:19]Abnormal findings such as murmurss, extras sounds, or irregular rhythms may indicate vavular disease or cardiac dysfunction.

[00:18:29]If I can just get you to lay back just a little bit. And is it okay if we pull up your gown and keep you covered, but reveal your abdomen?

[00:18:43]>> Yes.

[00:18:48]>> Okay.

[00:18:49]just a little bit. So now I will inspect the abdomen for contour, symmetry, and skin characteristics such as scars or distension.

[00:19:02]Now I will oscultate or listen to the bow sounds in all four quadrants prior to palpation to avoid altering findings.

[00:19:13]Have you had any diarrhea or constipation in the last couple weeks?

[00:19:17]>> Okay.

[00:19:19]Do you know when your last bowel movement was?

[00:19:32]>> Sorry.

[00:19:55]I would also listen for vascular brewies which may indicate arterial narrowing. And now I will perform light palpation in all quadrants assessing for tenderness, guarding or masses.

[00:20:10]I'm just going to lightly touch your abdomen. If you have any discomfort, please let me know.

[00:20:22]None of that hurts.

[00:20:23]>> No.

[00:20:24]>> Okay, you can put your shirt back down.

[00:20:30]>> You still need one of them.

[00:20:33]>> No. Normal findings include active bowel sounds and soft, non-tender abdomen.

[00:20:38]Abnormal findings such as absent bowel sounds, tenderness or masses may indicate gastrointestinal or vascular concerns.

[00:20:47]Now I will inspect the upper and lower extremities for skin color, temperature, hair distribution and nail condition.

[00:20:56]So everything looks okay. Now I will assess capillary refill which should be less than two seconds.

[00:21:08]And even though she has fake nails on, I was still able to see at the base of her nail that she has a brisk capillary refill.

[00:21:18]Now, oh, and I will also assess the lower extremities. You can lean back a little bit if you need to for comfort.

[00:21:41]All right.

[00:21:49]I also assess capillary refill in the toes to to ensure adequate cardiac function.

[00:22:01]Now I will assess or palpate the peripheral pulses and assess for any edema.

[00:22:11]Good.

[00:22:15]Good.

[00:22:20]Good.

[00:22:38]Normal findings include warm skin, brisk capillary refill refill, and strong pulses. Abnormal findings may indicate circulatory compromise or fluid imbalance.

[00:22:50]Now I will inspect and palpate joints for swelling, deformities or tenderness.

[00:23:01]>> Is that hurt anywhere?

[00:23:07]>> How about there?

[00:23:14]How about there?

[00:23:18]How about there?

[00:23:20]Ticklish.

[00:23:21]>> Yeah.

[00:23:22]>> How about there?

[00:23:23]>> No.

[00:23:25]>> In there.

[00:23:26]>> No.

[00:23:27]>> Okay.

[00:23:31]And now I will assess active range of motion in all major joints and test muscle strength against resistance.

[00:23:41]Okay. So, could you hold your arms out for me? Could you raise them above your head? Could you lower them down? Okay.

[00:23:48]Put your arms up. Don't let me push down.

[00:23:53]Don't let me push them up.

[00:23:55]Same with your legs. Can you raise your legs up while they are up?

[00:24:02]And how about down? Okay. Now, put them back up for me just for your comfort.

[00:24:08]Okay. Now, don't let me push them down.

[00:24:11]Don't let me pull them up. Okay.

[00:24:15]Now I will observe functional movement such as walking, bending and balance.

[00:24:22]Now for this I will need you to stand for me.

[00:24:30]Let me know when you are situated. Okay.

[00:24:35]All right.

[00:24:37]So normal and findings would include full range of motion motion and strength limitations or pain may indicate muscular skeletal injury, arthritis or neurological conditions. So could you walk from here to there and back and then stand and look at me?

[00:25:04]Can you bend down and touch toes?

[00:25:06]Okay. Can you squat?

[00:25:11]Okay, good job.

[00:25:14]Now you stand like this and hold your hands out.

[00:25:18]Now take your right hand and touch your nose and back and your left hand and touch your nose.

[00:25:26]Good job.

[00:25:32]Now I will assess sensation using light touch across multiple areas of the body.

[00:25:41]And for that I will need you to have a seat again.

[00:25:51]So you just tell me if you can feel where I'm touching.

[00:26:08]Sorry. Is that ticklish?

[00:26:10]>> Yes. Now I will assess the Romberg test. So if you could just hold your leg up for me.

[00:26:29]Um so normal findings would include coordinated movement, intact sensation, and appropriate reflexes. Abnormal findings may indicate central or peripheral nervous system dysfunction.

[00:26:47]I will also evaluate deep tendon reflexes such as fatellar reflex to evaluate neurological integrity. So just I'm just going to lightly tap. Okay.

[00:27:03]And this one.

[00:27:05]Good job.

[00:27:09]So health promotion for this patient includes maintaining a balanced diet, engaging in regular physical activity, ensuring adequate sleep, and participating in routine health screenings such as blood pressure and cholesterol checks.

[00:27:25]These interventions help reduce the risk of chronic disease and support overall health and wellness.

[00:27:34]So that concludes my assessment. Do you have any questions or concerns? Nope.

[00:27:39]>> Thank you for participate for your participation and I am now performing my hand hygiene.