What is a head-to-toe assessment?
A head-to-toe assessment is a comprehensive method used by nurses and other healthcare providers to evaluate the overall health status of a client. This systematic and structured evaluation includes physical, mental, and physiological assessments, typically starting from the head and moving down the body to the toes.
How to do a head-to-toe assessment
Starting at the head, move down the client’s body, conducting evaluations of each body system:
- General impression: level of consciousness, skin color, facial expression, personal hygiene; signs of distress?
- Vital signs: temperature, pulse, respiration rate, blood pressure, pain levels
- Neurological: orientation to time, place, and person; pupillary responses, strength, coordination, reflexes
- Head and integumentary system: scalp, face, eyes, ears, nose, mouth, and skin; is there any discharge, swelling, or other abnormalities?
- Neck: lymph nodes, trachea and thyroid gland, range of motion
- Chest: heart sounds, lung sounds front and back; symmetry in chest movements
- Upper and lower extremities: symmetry, strength, range of motion, condition of skin and nails, radial pulses, capillary refill
- Abdomen: contour, symmetry, any masses, movement, bowel sounds in all quadrants; is there any tenderness or organomegaly?
What are the 4 primary tools of assessment?
The 4 primary tools of physical assessment are:
- Inspection: visual examination, looking for any visible abnormalities (e.g. color changes)
- Palpation: manually feeling for abnormalities (e.g. lumps, masses, or areas of tenderness)
- Percussion: tapping on the client’s body to produce sounds that can give clues about the underlying structures (e.g. hollow vs dull sounds over lungs)
- Auscultation: listening to sounds produced by the body, usually with a stethoscope (heart sounds, breath sounds, bowel sounds)
Note: For an abdominal examination, the usual order changes. To assess undisturbed bowel sounds, the order is to inspect, auscultate, percuss, then palpate.
Tips for doing head-to-toe assessments
- Be systematic: It’s called head-to-toe for a reason–thoroughly move down the body, taking in the big picture as well as the details of each specific assessment.
- Compare sides: Always check both sides and make sure you find asymmetries or issues that may only occur on one side.
- Take notes: Note down your findings as you go, so that you don’t forget details when documenting the assessment.
When are head-to-toe assessments done?
Head-to-toe assessments are typically done whenever healthcare personnel need to take stock of a client’s overall health status. This could be when a client is first admitted to a hospital, at the beginning of a nursing shift, whenever there is a significant change in a patient’s condition, or following a regular schedule of assessments based on facility policy or monitoring guidelines.
What kinds of nursing assessments are there?
Different specific physical assessments that nurses do include:
- Cardiovascular assessment: heart rate and rhythm, heart sounds, peripheral pulses, and signs of peripheral vascular disease
- Respiratory assessment: rate and depth of respiration, ease or difficulty of breathing, lung sounds, and use of accessory muscles
- Gastrointestinal assessment: inspection of the abdomen, auscultation of bowel sounds, percussion, palpation for tenderness or masses, and assessing the patient’s appetite, diet, and bowel habits
- Neurological assessment: evaluation of level of consciousness, pupil size and reactivity, symmetry and strength of movement, reflexes, sensation, and orientation
- Musculoskeletal assessment: assessment of range of motion, muscle strength, and gait, any deformities, pain, or weakness
- Skin assessment: inspecting the skin for color, temperature, moisture, turgor, and integrity, any wounds, rashes, or pressure ulcers
