Head-to-Toe Assessment in Nursing: A Step-by-Step Guide
Head to Toe Assessment Checklist Template
Get an example head-to-toe assessment template today! Perfect for a nursing student or a practicing nurse in the field.
Listening to a patient verbalize multiple symptoms may seem overwhelming — particularly when you don’t know the exact diagnosis. The first step in the nursing process is assessment.
This type of assessment helps the nurse gain a more complete understanding of the patient’s current state and the potential reason behind the signs and symptoms they’re experiencing.
In addition, the results of this assessment will be relayed to the health care provider (HCP) and will allow the nurse to create a nursing care plan that will guide the patient’s care. Therefore, accuracy is crucial to the well-being of your patient.
What Is a Head To Toe Assessment?
A head-to-toe assessment is a health evaluation that a nurse administers to better understand a patient’s status. As a nurse, this process helps you better understand your patient’s needs.
The assessment encompasses every body system and the patient’s mental and neurological needs.
Head to Toe Assessment Checklist
Now that you know what a nursing assessment is and when to use this process, we will walk you through how to conduct your head-to-toe nursing assessment (including what to look for during each phase).
Head to Toe Assessment Example
Gather Tools
Stethoscope
Gloves
Watch with Second Hand
Penlight
Hand sanitizer
Wound measurement tool
Prepare for Assessment
Wash your hands.
Clean reusable tools.
Check the room for transmission-based precautions.
Greet & Inform
Knock before entering.
Greet the patient and any others in the room. Ask the patient how they prefer to be addressed.
If others are present, ask patient if they can stay for exam.
Introduce yourself (name and role).
Listen actively and attend to patient cues throughout.
Explain the procedure, including what will be done and how long it will take.
Ensure privacy and confirm the patient is comfortable with others present.
Initial Assessment Steps
Your initial assessment involves everything you notice about the patient as soon as you walk into the exam room, including both subjective and objective observations. The first interaction portion of the assessment can help determine the patient’s chief complaint along with their mental status.
Things to look for during the initial assessment include:
Whether the patient appears alert, greets you, and answers questions appropriately
Signs of patient distress, including labored breathing and/or confusion
Overall appearance, including if they seem dressed appropriately, their basic hygiene, and their posture.
Overall health history
1. Patient Identification
Confirm patient identity using two appropriate identifiers.
2. Primary Survey
Check for immediate medical stability:
Airway: Is it open? Is suctioning needed?
Breathing: Is it normal?
Circulation: Look for cyanosis, diaphoresis, or other skin abnormalities.
Mental Status: Is the patient alert and responsive?
3. General Survey
Observe general appearance, behavior, mood, mobility, communication, nutritional status, and fluid status.
4. Address Patient Needs
Ensure patient comfort (toileting, glasses, hearing aids, etc.) before starting.
5. Chief Concern Evaluation:
Use PQRST to assess the patient’s primary reason for care. Ask if they have any concerns or questions before beginning.
6. Vital Signs:
Obtain or review vital signs. Initiate emergency assistance if needed.
7. Pain Assessment:
Evaluate for pain or discomfort. If present, perform a comprehensive pain assessment using PQRST.
You will want to examine the head for discomfort or abnormalities.
Things to look for during the head assessment include:
Inspection with your eyes to check for any signs of asymmetry, or edema
Inquiring about any pain or discomfort
Examining the facial nerve by asking the patient to smile and raise their eyebrows
Touching (palpation) for any tenderness or edema
Neck Assessment
Use your eyes to visually examine the patient’s neck, and use your hands to carefully palpate the area to look for any signs or symptoms.
Assessment of the neck should include:
Assessment of the patient’s spinal accessory nerve while asking the patient to shrug their shoulders. Abnormalities can be found during this assessment.
Inspecting any limited range of motion in the neck by having the patient rotate their head in various directions
Palpating the neck for swelling or enlarged lymph nodes or glands
Inspection of the patient‘s neck for a tracheal deviation.
Noting any signs of an enlarged thyroid gland by palpating while the patient swallows some water.
Eyes Assessment
Assessment of the eyes include:
Inspecting the sclera, assessing for signs of discharge, redness, lesions, or other abnormalities
Inspection of the pupils with a pen light to check the pupillary response to light and movement. (PERRLA=pupils equal, round, reactive to light and accommodation) Also noting the size of the pupils as well.
Inspection of the patient’s six extraocular eye muscles to determine how well they are working along with cranial nerves, III, IV, and VI.
Using a visual acuity test to see how the optic nerve performs
Nose and Sinus Assessment
Examining the nose and sinuses can assess any issues with smell, potential sinus infections, or other damage to the area.
Tips for examining the nose and sinus area include:
Using your otoscope to examine the inside of the nose also while Inspecting the septum
Palpate the sinuses for tenderness
Use scented objects to test the olfactory nerve for smell
Checking for signs of discharge or nasal polyps
Ears Assessment
Recommendations for assessing the ears include:
Inspection of the outer and inner ear
Palpate for any tenderness
Utilize an otoscope to assess the cone of light
Assess for signs of lesions, discharge, bulging, or any inner scarring
Perform the whisper test to see the function of the vestibulocochlear nerve
Mouth and Throat Assessment
Ask your patient to open their mouth to closely examine the mouth and throat.
Upon examination of the throat and mouth, inspect the following:
Signs of swelling of the lips, tonsils, uvula, or elsewhere in the mouth
Lesions or other abnormalities of the mucosa
Cracked or dried lips or other signs of dryness
A hairy tongue
Ask the patient if they have had any difficulty with tasting foods, swallowing, or gagging.
Chest Assessment
The chest area can provide valuable insight into the patient’s respiratory and cardiovascular health.
Assessment of the cardiovascular system includes:
Ask about chest pain, shortness of breath, palpitations, or lower extremity pain.
Inspect for pallor, cyanosis, JVD, and signs of DVT.
Palpate pulses and check capillary refill.
Auscultate heart sounds in all five areas, noting rate, rhythm, S1, S2, and any irregularities.
Assessment of the respiratory system includes:
Ask about shortness of breath, cough, smoking habits, and interest in quitting.
Inspect skin color, breathing patterns, and trachea alignment.
Auscultate lung sounds and note any abnormal findings.
If using oxygen, document the type, flow rate, and inspect for skin breakdown.
Abdomen Assessment
To assess the abdomen properly, you must first inspect. Next, you will auscultate before any palpation or percussion to avoid disturbing bowel sounds. If the patient is experiencing abdominal pain, they will guard the abdomen, and likely you will not get a chance to auscultate.
Tips for examining the abdomen include:
Looking for new or differing skin pigmentation.
Checking for tenderness.
Looking for any signs of protrusions.
Using auscultation to see if you hear abnormal bowel sounds in any of the four abdominal quadrants. If no bowel sounds are present, you must auscultate all four abdominal quadrants for five minutes each before charting no bowel sounds.
Inspecting any abdominal pulsations.
Inquiring about signs of gastrointestinal health, such as abnormal bowel movements, as well as the last bowel movement.
Pulses and Vascular Assessment
The patient’s pulses can provide valuable information about overall health. The following pulses should be assessed (palpated ) in a head to toe assessment: temporal, carotid, apical (with cardiac), brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulse.
Things to look for when assessing the veins and pulses include:
Palpating and document pulses. Prompt intervention for absent pulses.
Observing any signs of arterial or venous disease
Inspecting the skin for discolorations
Checking for signs that the capillaries are not refilling properly
Extremities and the Musculoskeletal System Assessment
Assessment of the musculoskeletal system involves a range of motion (active or passive) and strength of extremities.
An extremity and musculoskeletal system assessment will likely include:
Assessment of difficulty independently moving upper or lower extremities.
Assessment of strength in the upper and lower extremities.
Examining the patient to see if they can identify sharp and dull sensations on their extremities
Inspecting signs of abnormalities in the fingernails and toenails
Neurological Assessment
You also need to closely examine the patient’s mental state for signs of delay or confusion.
Assessment of the neurological state includes:
Ask about headaches, dizziness, weakness, numbness, tingling, tremors, falls, or difficulty swallowing.
Assess level of consciousness, orientation, and PERRLA with a penlight.
Evaluate motor strength and sensation in hands, upper, and lower extremities.
Note any unexpected findings and seek emergency assistance if needed.
Assess fall risk as per agency policy.
When Is a Head To Toe Assessment Typically Performed?
As a nurse, you are most likely the patient’s first encounter with a health care individual when they are seeking medical treatment. To begin, you’ll want to perform a complete health assessment to understand your patient’s needs best, and to pass this information along in your nursing hand-off report effectively.
