In this step-by-step guide to performing a head-to-toe nursing assessment, you will get an overview of what you need to perform this assessment and obtain the information you need to provide quality care. Both nurses and nursing students must know how to perform this assessment properly.
This guide is in full detail, and some of the more focused components of the assessment are not routinely performed in all areas of nursing, so do not use it to replace your standards of practice. Rather, this information is an in-depth dive into the various components of a complete head-to-toe assessment.
This information presented here does not replace your nursing education and training, and most hospitals/facilities have their own processes for the nursing head-to-toe assessment or a focused assessment - so check the policies regarding the complete assessment in the setting in which you work.
Why Is a Head-to-Toe Assessment Important in Nursing?
As a nurse, you know the importance of the head-to-toe nursing assessment. It is essential to obtain the data to understand how your patient is, make a diagnosis, and decide what steps to take to help the patient recover. The nursing process, the framework for the nursing practice, has the patient assessment as one of the steps to provide holistic, quality care focused on the patient.
The head-to-toe assessment is a physical evaluation performed systematically on each part of the body. It helps identify a patient’s health status and needs to make a care plan and consider possible issues.
There are different types of head-to-toe assessments. The first is the complete one, which covers all the body areas and systems. Usually, registered nurses (RNs) perform this assessment in annual care visits or patient admissions.
The second type focuses more on the body areas or systems where RNs identify problems in the patient. Registered nurses perform this type of assessment to keep under observation the concerns found in the patient and evaluate the goals related to the concern.
Physical Nursing Assessment Techniques
You will use different techniques in a nursing assessment to gather the patient health data you need. The order of the nursing assessment techniques is as follows: inspection, palpation, percussion, and auscultation, methods explained briefly below:
- Inspection: This is the first technique you will apply in any assessment. For this method, you will use your eyes and nose to check different body areas to find abnormal conditions like swelling or skin rash.
- Palpation: In this technique, you will use your hands to feel the patient’s body. There are two types of palpation. First, we have light palpation, which is gentle and helps to understand the patient’s fluids, skin moisture and texture, and muscle guarding, among others. The second method is deep palpation, which allows RNs to understand what is happening in the body’s internal structure and check organs, masses, areas in pain, and more.
- Percussion: In this method, RNs will tap different body areas to produce sound waves that help them identify the presence of air, solids, and fluids. In addition, registered nurses can also check the size, position, and shape of the organs.
- Auscultation: With the help of a stethoscope, nurses will listen to different systems of the patient’s body, such as the respiratory or the cardiovascular system, looking for any anomaly in the sound of the heart or the respiratory tract, among others.
Nursing Assessment Equipment Checklist
To perform a head-to-toe assessment, RNs must have equipment for gathering patient data. The following list shows this fundamental equipment:
- Thermometer
- Gloves
- Stethoscope
- Tongue depressor
- Penlight
- Scale
- Blood pressure cuff
- Height wall ruler
- Tape measure
- Reflex hammer
- Sterile objects
- Alcohol swabs
Starting the Nursing Assessment Process
You must create a safe environment for the patient: Introduce yourself, check the patient’s ID, explain what you will do, and let them know you will answer all their questions. It is essential to have the patient’s consent before beginning the assessment. The first thing you will do as a nurse is start making mental notes of what you see from the moment you enter the room. Look at the following as a basic checklist:
- Does the patient answer appropriately, or are they suffering any distress?
- How are their appearance, posture, and hygiene?
- Be aware of any abnormal smell.
- Ensure patient stability
- Check if the airway is open and whether the patient is breathing normally.
- Determine whether the patient has any abnormalities in their skin’s overall color and moisture.
It is essential to mention that any head-to-toe assessment example or template should contemplate all the verification steps so you don’t miss anything.
Head-to-Toe Assessment Checklist
A head-to-toe assessment has several steps, and remembering them can sometimes be tricky. For that reason, we will explain every detail of the nursing steps for this assessment:
Taking a Patient Overview
This overview is the first step of the assessment. You collect the patient’s vital signs, like heart rate, blood pressure, body temperature, oxygen saturation, and respiratory rate. You also determine pain levels using the mnemonic PQRSTU, calculate the body mass index (BMI), and obtain the patient’s health history.
In case you are not familiar with the mnemonic PQRSTU, we are going to explain it below:
- Provocative/Palliative: What makes the pain worse? What makes the pain feel better?
- Quality/Quantity: How does the pain feel (burning, aching)? How bad is your pain?
- Region/Radiation: Where is the pain? Is it in other parts of the body?
- Severity: Ask the patient to scale the pain from one to 10.
- Timing/Treatment: When did the pain start? How long has the patient had it? Is the patient taking something for the pain?
- Understanding: What is causing the pain?
In this step, you can find the main reason the patient seeks medical attention.
Hair, Nails, and Skin
Start the assessment from the top, looking for some disease or disorder that can come up. In this part of the assessment, you will be looking for the following:
- Lesions or bumps on the scalp
- Hair distribution (even or uneven)
- Hair dryness, oiliness, lesions, and parasites
- Rashes, lumps, and lesions in the skin
- Capillary refill
- Skin texture, moisture, and color consistency
- Skin integrity and thickness
- Edema
- Signs of pain
Head
You want to check for any anomalies.
- Check for any asymmetry or edema.
- Look for signs of pain.
- Look for nodules or masses.
- Check if the face is smooth.
- Examine the facial nerve, asking the patient to smile and raise their eyebrows.
- Check for signs of edema.
Eyes
For the eyes assessment, you will be looking for the following:
- Evaluate visual acuity.
- Assess eye symmetry.
- Determine whether the pupils are equal, round, and react to light and accommodation (PERRLA).
- Inspect the external eye structures.
- Check the six extraocular eye muscles.
- Check the sclera.
- Inspect the retina.
- Check the optic disk.
Nose and Sinus
By assessing the nose and sinus, you can determine problems with the patient’s sense of smell, sinus infections, or any damage to the area.
- Use palpation to check for symmetry.
- Inspect the nostrils and the septum.
- Use alcohol swabs to test the olfactory nerve.
- Check for nasal polyps.
- Palpate sinuses.
- Inspect nasal patency.
Ears
To perform this assessment, this is what you need to look for:
- Check the inner and outer ears.
- Check for drainage or anomalies.
- Inspect the tympanic membrane.
- Perform the Weber’s test.
- Perform the Romberg test.
- Perform the Rinne test.
Mouth and Throat
In this part of the assessment, it is necessary to check the following:
- Lips
- Teeth and gums
- The buccal mucosa
- The tongue
- The odor of the mouth
- The hard and soft palates and uvula
- The patient’s ability to swallow and taste
- Their gag reflex
Neck
Use palpation to find signs of abnormalities. Here is what you will look for:
- Look for lumps or masses
- Check the neck movement and structure
- Palpate and auscultate the thyroid gland
- Palpate the trachea
- Palpate lymph nodes
Chest
In this assessment, you will check the respiratory and cardiovascular system.
- Auscultate the heart at the apex, the base, and the aortic and pulmonary areas to look for unusual sounds.
- Check pulse.
- Auscultate the lung sounds in all fields (anterior, posterior, and lateral).
- Check chest expansion.
- Check for efforts to breathe or coughing.
- Palpate the thorax.
- Check breathing sounds.
- Check for cyanosis.
Abdomen
For this assessment, you need to collect subjective data by asking the patient about their bowel movements, symptoms, lifestyle, and diet.
- Auscultate for bowel sounds in every quadrant.
- Auscultate for vascular sounds.
- Palpate the four quadrants to check for pain and outline abdominal organs.
- Check for masses.
- Palpate the liver, spleen, kidneys, urinary bladder, and the aorta.
- Percuss for tone in every quadrant.
Learn More: Understand the Difference Between Subjective and Objective Data
Genitals
This evaluation can be more sensitive for the patient, so ensure you are very gentle.
In both men and women,
- Palpate inguinal lymph nodes.
- Inspect for femoral or inguinal hernia.
- Check the perianal and sacrococcygeal area.
In men,
- Check the base of the penis.
- Palpate the shaft and check the skin.
- Check the scrotum size, shape, position, and any abnormality or mass.
- Check the prostate.
- Palpate the anus, rectum, and peritoneal cavity.
- Check the stool.
In women,
- Check the vaginal opening and major and minor labia.
- Check the clitoris and the urethral meatus.
- Inspect Bartholin’s glands.
- Check the symmetry and size of the breasts.
- Check aureolas, nipples, and venous patterns.
- Palpate for masses, texture, elasticity, and temperature.
Extremities and Back
In the assessment, you will check the range of motion, strength, and abnormalities.
- Assess strength and range of motion in arms/legs/ankles.
- Assess sharp and dull sensations in arms/legs.
- Assess gait.
- Inspect for abnormalities in fingernails and toenails.
- Check for edema, pain, and any other abnormalities.
- Perform a Phalen’s test.
- Inspect the thoracic, lumbar, and cervical curves, looking at the patient from behind and the side.
- Check for back and leg pain.
- Check the coccyx.
Neurologic system
In this assessment, you will check your patient’s neurological health.
- Check balance.
- Test reflexes.
- Test cranial nerves from I to XII.
- Test fine motor skills and coordination.
- Perform the Glasgow Coma Scale.
- Perform the primary sensory function test.
At this point, you will finish the assessment and can answer any questions your patient could have. However, there are some additional essential steps to complete your task.
Proper Documentation of Head-to-Toe Assessment
Nurses must make precise, objective, and clear documentation for better patient outcomes. Whether you use a computer charting system or have to handwrite your findings, it is essential to organize the documentation so the healthcare team can make proper care plans for the patient.
Time can play against nurses since they have hectic days. However, performing this assessment and documenting it is essential to obtain patients’ data, which is crucial to guide their treatment plans and give quality care.
Find Nursing Jobs and Start Assessing Patients
Now that you have refreshed your knowledge of head-to-toe nursing assessments, you can look for per diem jobs near you. A per diem job means working in fixed-time conditions or working by the shift. If you want to make more and gain more flexibility, Nursa has many per diem job opportunities for you.
Nursa is an open market where you can find per diem jobs in your area. Download the app today and pick up per diem nursing jobs.
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