The Basics of the Head to Toe Assessment:

This is 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. When you enter the
room, attempt to establish eye contact with the patient. This will show
you if they are alert or if this needs to be further investigated. Address
them by name and introduce yourself. When they answer you, this will
show you how clear their speech is and if they are oriented to self. Do
their eyes meet yours or do they wander? Are they blind or hearing-
impaired? This can all be determined in a few seconds.

Difficulty: Average
Time Required: Approximately 10-20 minutes

Procedure:

1. 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 he/she feels and observe
the environment. As you assess the body by systems, observe for
such tings as non-verbal cues, mobility and ROM.
2. HEENT/Neuro:
o Head: shape and symmetry; condition
of hair and scalp
o Eyes: conjunctiva and sclera, pupils;
reactivity to light and ability to follow
your finger or a light
o 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.
o Nose: drainage, congestion, difficulty breathing, sense of
smell
o Throat and Mouth: mucous membranes, any lesions, teeth or
dentures, odor, swallowing, trachea, lymph nodes, tongue
3. 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).
4. 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 Have them roll over on
their side, and check their back, buttocks, and perineal area if
appropriate for the situation. This will also help you tell how well
they can move around in the bed.
5. 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. While you listen to their
breath sounds, you can check the skin for lesions and assess the
condition of dressings.
6. 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.
Assess genitalia for tenderness, lumps or lesions.
7. Extremities: Assess for temperature, capillary fill and ROM. Palpate
for pulses. Note any edema, lesions, lumps or pain. Ask them if
they feel pain when you touch them, check for the Homan's sign.
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?
8. Wash your hands.
Document your findings.
Report any significant changes or findings to the PCP (primary care
practitioner).
9. 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

Make sure while you are doing your assessment to ask the patient if
they have any special needs during their stay. A lot of time nurses
miss things simply because they don't ask the patient if they need help
to the restroom, if they're hard of hearing, or if they have poor night
vision. Most patients will share with you if you ask. They'll tell you
they're incontinent at night or that they wear dentures or other things
of importance if you'll just take a few minutes and listen to them. This
is as important as your physical assessment and will leave a lasting
positive impression on the people you care for during your shift.