This article describes the basics of a head-to-toe assessment which is a vital aspect of

nursing. It should be done each time you encounter a patient for the first time each
shift (or visit, for home care, clinic or office nurses).
This assessment includes assessment of the physical, emotional and mental aspects of
all body systems as well as the environmental and social issues affecting the patient.
The nurse needs to observe for all of these factors and ask questions as needed.
Difficulty: Average
Time Required: Approximately 10-20 minutes
Procedure:
Assemble your equipment. Wash your hands. Greet and identify the patient. Explain
what you are going to do. Provide for privacy. Begin with the 5 Vital Signs:
Temperature, Pulse, Blood Pressure, Respiration and Pain. Ask the patient how feels
and observe the environment. As you assess the body by systems, observe for nonverbal cues, mobility and ROM.
HEENT/Neuro:
Head: shape and symmetry; condition of hair and scalp
Eyes: conjunctiva and sclera, pupils; reactivity to light and ability to follow your
finger or a light
Ears: hearing aids, pain? Speak in a whisper: can he hear you and comprehend? Turn
away to make sure he isn't reading your lips.
Nose: drainage, congestion, difficulty breathing, sense of smell
Throat and Mouth: mucous membranes, any lesions, teeth or dentures, odor,
swallowing, trachea, lymph nodes, tongue
Level of Consciousness and Orientation: Is he awake and alert? Is he oriented to
Person (knows his name), Place (he can tell you where he is) and Time (knows the
day and date). A fourth level of orientation is Purpose (he knows why you are
examining him; or knows the function of something such as your penlight or
stethoscope).
Skin: As you examine all body systems you need to make note of the status of the
Integumentary System for any breaks in the skin, scars, lesions, wounds, redness, or
irritation. Assess the turgor, color, temperature and moisture of the skin.
Thoracic region: Assess lung and cardiac sounds from the front and back. Assess them
for character and quality as well as for the presence or absence of appropriate sounds.
Palpate the chest wall and breasts for any tenderness or lumps.
Abdomen: Listen to bowel sounds throughout the 4 quadrants. Palpate for tenderness
or lumps. Palpate the bladder. Ask about intake and output of bowels and bladder. Ask
about appetite. Asses genitalia for tenderness, lumps or lesions.
Extremities: Assess for temperature, capillary fill and ROM. Palpate for pulses. Note
any edema, lesions, lumps or pain.
General Questions: Ask the patient how he feels. Has anything changed recently? Any
pain, burning, SOB, chest pains, change in bowel or bladder habits/function, change
in sleep habits, cough, discharge from any orifice, depression, sadness, or change in
appetite?
Wash your hands. Document your findings. Report any significant changes or findings
to the PCP (primary care practitioner).
Evaluate your assessment in terms of The Nursing Process

What You Need:

Stethoscope
Thermometer
Sphygmomanometer
Penlight
Tape measure
Watch with second hand
Pen
Assessment forms or note paper