Head-to-Toe Assessment in Nursing: A Step-by-Step Guide

Head to Toe Assessment Checklist Template

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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).

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.

• Precipitating factors (what causes the pain)
• Quality (throbbing, aching, stabbing)
• Region or radiating
• Severity (pain scale 1-10)
• Time (when did it begin?, how long does it last?)

Specific Assessments

Head Assessment

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.

Some instances where you would need to conduct a nursing assessment include:

• When a patient presents to the emergency room/department (ER/ED), the Registered nurse will conduct a head-to-toe assessment to ensure the patient’s records contain the most accurate information regarding their health history.
• When a patient is admitted to a hospital unit, a Registered nurse is responsible for the initial assessment and assessments per shift to assess for any changes.
• If you are a nurse practitioner (NP) conducting physical examinations, the head-to-toe assessment will assist the NP in making a proper diagnosis for treatment of the patient.
• Keeping accurate updates of head-to-toe assessments helps pediatric nurses understand the year-over-year development of the children they work with, and helps geriatric nurses understand the improvement or decline in the health of the patients they see and treat.

Head To Toe Assessment Tips

As you begin to examine the patient carefully, look for and note signs and symptoms related to the patient’s hair, skin, and nails. These notes can tell you quite a bit about their overall health.

Areas to pay attention to during the hair, skin, and nails assessment include:

• Nails: signs of delayed capillary refill, > 3 seconds, clubbing, or fungus of the nail beds
• Hair: signs of uneven hair distribution
• Skin: checking for rashes; changes in skin color, such as pallor or erythema; signs of decreased skin turgor or lesions; checking for hot or moist skin

Master the Fundamentals with SimpleNursing

Learning how to complete head-to-toe assessments will help you perform better as a future nurse or nursing student. Taking this holistic look at the individual by examining all body systems can help you spot potential problems and gain a complete picture of your patient’s health.

To continue excelling in nursing school, you must also prepare for important nursing exams like the NCLEX. SimpleNursing has set out to conveniently create all the resources you need to study for any upcoming nursing examinations.

See what we can offer you as a nursing student.