A head to toe assessment is a comprehensive physical examination that nurses perform to gather baseline data, identify health concerns, and monitor changes in a patient’s condition. It follows a systematic approach from the top of the body to the bottom, ensuring no system is overlooked.
Pre-Assessment Preparation
- Review patient’s medical history and chart.
- Ensure patient’s privacy and comfort.
- Wash hands and wear gloves (if necessary).
- Introduce yourself and explain the assessment process.
What Methods of Examination Do You Use in a Head-to-Toe Assessment?
There are several procedures for performing a physical examination. While inspecting a patient in detail, you will use four main methods. We’ll describe briefly what they are and what they entail.
Inspection
Always performed first, inspection also is the most repeated method of examination. You need to use your sight and smell to check specific body areas for normal color, shape, and consistency.
Palpation
Touching the patient to sense abnormalities on (or in) the body is known as palpation. In the process of conducting a head-to-toe assessment, you will employ two kinds of palpation: light and deep. Light palpation is gentle and gives information about skin texture and moisture, fluids, muscle guarding, and some superficial tenderness the patient may be experiencing. On the other hand, deep palpation explores the internal structures of the body to a depth of four to five centimeters. Using this technique, RNs can learn more about organs and masses’ position, shape, mobility, and possible areas of discomfort.
Percussion
This third technique requires the nurse to tap on the patient’s body to produce sound vibrations. These sounds can confirm the presence of air, fluid, and solids. It can also pinpoint organ size, shape, and position.
Auscultation
The last method of examination is auscultation. It implies listening to the heart, lungs, neck, or abdomen to gather information. Direct auscultation is done with the unaided ear. Indirect auscultation requires the presence of amplification or mechanical devices, such as a stethoscope.
How Do You Start an Assessment?
The first thing you need to do before starting an assessment is to build rapport with the patient. Introduce yourself, explain what you will be doing, ask what brings them to the doctor’s office. Address any questions they may have before you begin. Ask if there’s something you could do to make them more comfortable, like changing the room’s temperature or the lighting. It’s essential to build a relationship with the patient before the actual physical examination begins.
From the moment you walk into the room, you should start making mental notes of certain physical clues the patient might display:
- Their general appearance (How does their hygiene, dress, affect seem?)
- Their posture (Do they seem to experience problems sitting/standing?Are they grunting during movement?)
- Is their speech clear or slurred?
- Are there any abnormal smells?
- Their alertness (Can they answer questions? Are they reluctant to speak?)
- Signs of distress (Do they seem visibly confused, pale? Do they have problems breathing? Are they avoiding eye contact?)
Once you have established a relationship with the patient, you can begin the assessment.
Head-to-Toe Assessment Equipment Checklist
Depending on the type of assessment conducted, the nurse may need specific equipment.
Basic equipment includes:
- Gloves
- Thermometer
- Blood pressure cuff
- Watch
- Scale
- Height wall ruler
- Tape measure,
- Penlight
- Stethoscope
Additional equipment for more comprehensive examinations would include,
- Otoscope
- Ophthalmoscope
- Reflex hammer
- Tongue depressor
- Sterile sharp object (like toothpick or pin)
- Sterile soft object (like cotton ball)
- Something for the patient to smell (like an alcohol swab)
How Long Are Head-to-Toe Assessments?
Ferere explains that the duration of the exam is directly correlated to the patient’s overall health status.
“Health patients with limited health histories may be completed in less than 30 minutes,” she says. “Many health practices have patients complete health history and pre-visit forms prior to presentation for a comprehensive visit. Review of these forms in advance can certainly reduce the required visit time.”
Head-to-Toe Assessment
1. General Overview
First, you obtain a general overview of the patient’s health state. These are the details to keep an eye on in this phase of the assessment.
- Collect their vital signs. (It’s encouraged to ask permission before touching a patient. Also, explaining what you are doing/what assessment you are performing will help the patient feel more relaxed.)
- Check heart rate
- Measure blood pressure
- Take body temperature
- Pulse oxymetry
- Respiratory rate
- Check pain levels
- Check hight and weight and calculate their BMI
2. Hair/ Skin/ Nails
Once you have a general overview, you can start from the top of the body and make your way down. The assessment is called head to toe for a reason. Some things to look out for are:
- Hair distribution(even/uneven)
- Hair infestations (lice, alopecia areata)
- Bumps, nits, lesions on the scalp
- Tenderness on scalp
- Tenderness, lumps on the skin
- Lesions, bruising, or rashes on skin
- Temperature, moisture, and skin texture (is the patient pale, clammy, dry, cold, hot, flushed?)
- Edema
- Consistency, color, and capillary refill of nails
- Pressure areas
3. Head
- Shape is rounded, symmetrical
- Upon palpation, no nodules, masses or depressions are identified
- Face appears smooth and symmetrical with no nodules or masses present.
4. Eyes
- Check external structures
- Assess eye symmetry
- Check conjunctive and sclera
- Check for PERRLA
- Perform visual acuity test
- Check eyes for drainage
- Check vision with Snellen Chart
- Check six cardinal positions of the gaze
5. Nose
- Palpate nose and check symmetry
- Check septum and inside nostrils
- Patency of nares (patient can breath through each nostril)
- Check sense of smell
- Palpate sinuses
6. Mouth and Throat
- Check lips for color and moistness
- Inspect teeth and gums
- Examine tongue
- Inspect the inside of mouth
- Look at tonsils and uvula
- Assess hypoglossal nerve by asking patient to move tongue from left to right
- Check the patient’s ability to taste, to swallow, and their gag reflex
7. Ears
- Inspect for drainage or abnormalities
- Test hearing with whisper test
- Look inside ear: inspect the tympanic membrane and asses ear discharge
- Tuning fork tests (Weber’s Test, Rinne Test)
8. Neck
- Check neck muscles to be equal in size
- Palpate lymph nodes
- Check head movements and whether they happen with discomfort
- Observe neck range of motion.
- Check trachea placement
- Check shoulder shrug with resistance
9. Chest: Cardiovascular Assessment
- Listen to the heartbeat. Areas where to auscultate heart sounds: aortic, pulmonic, Erb’s point, Tricuspid, Mitral
- Palpate the carotid and auscultate apical pulse
10. Chest: Respiratory Assessment
- Auscultate lung sounds front and back
- Observe chest expansion
- Ask abour efforts to breathe/coughing
- Palpate thorax
11. Abdomen
- Inspect abdomen
- Listen to bowel sounds in all four quadrants
- Palpate all four quadrants of the abdomen to check for pain or tenderness
- Ask about bowel or bladder problems
12. Extremities
- Assess range of motion and strength in arms, legs, and ankles
- Assess sharp and dull sensation on arms and legs
- Inspect arms and legs for pain, deformity, edema, pressure areas, bruises
- Palpate radial pulses, pedal pulses
- Check capillary refill on fingernails/toenails
- Assess gait
- Assess handgrip strength and equality
13. Back area
- Inspect back and spine
- Inspect coccyx/buttocks
Documentation:
- Record findings in patient’s chart.
- Use standardized assessment tools (e.g., SOAP notes).
- Communicate findings to healthcare team.
Tips and Reminders:
- Use a systematic approach to avoid missing areas.
- Be thorough and meticulous.
- Use assessment tools (e.g., stethoscope, penlight).
- Consider patient’s cultural and personal preferences.
- Document accurately and thoroughly.
REFERENCES
- Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Appendix C – Head-to-Toe Assessment Checklist. Available from: https://www.ncbi.nlm.nih.gov/books/NBK593191/
- Dunham M, MacInnes J. Relationship of Multiple Attempts on an Admissions Examination to Early Program Performance. J Nurs Educ. 2018 Oct 01;57(10):578-583.
- Allen E, Williams A, Jennings D, Stomski N, Goucke R, Toye C, Slatyer S, Clarke T, McCullough K. Revisiting the Pain Resource Nurse Role in Sustaining Evidence-Based Practice Changes for Pain Assessment and Management. Worldviews Evid Based Nurs. 2018 Oct;15(5):368-376.
- Palmer RM. The Acute Care for Elders Unit Model of Care. Geriatrics (Basel). 2018 Sep 11;3(3)
- Jamieson H, Abey-Nesbit R, Bergler U, Keeling S, Schluter PJ, Scrase R, Lacey C. Evaluating the Influence of Social Factors on Aged Residential Care Admission in a National Home Care Assessment Database of Older Adults. J Am Med Dir Assoc. 2019 Nov;20(11):1419-1424.
- Gray LC, Beattie E, Boscart VM, Henderson A, Hornby-Turner YC, Hubbard RE, Wood S, Peel NM. Development and Testing of the inter RAI Acute Care: A Standardized Assessment Administered by Nurses for Patients Admitted to Acute Care. Health Serv Insights. 2018;11:1178632918818836.
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