How to Conduct a Head-to-Toe Assessment
Being a nurse means being a lot of things to a lot of people. But one of the basics of nursing is performing a head-to-toe assessment. We've put together a step-by-step guide to what happens in a nursing assessment and how nurses should understand the physical, emotional and mental aspects of someone’s body systems.
Learn From the Experts
We interviewed two healthcare experts to learn their best practices for conducting head-to-toe assessments. Terri Zucchero PhD, RN, FNP-BC is a nurse practitioner at Boston Health Care for the Homeless Program. Haynes Ferere, DNP, FNP-BC, MPH, serves as a clinical instructor at Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.
This article has also been reviewed by our panel of experienced registered nurses:
- Tyler Faust, MSN, RN
- Chaunie Brusie, BSN, RN
- Kathleen Coduvell Gaines, BSN, RN, BA, CBC
What is a Head-to-Toe Assessment?
A head-to-toe assessment refers to a physical examination or health assessment, and it becomes one of the many important components of understanding a patient’s needs and problems.
Head-To-Toe Assessment Basics
Types of Assessments
There are several types of assessments that can be performed, says Zucchero.
- A complete health assessment is a detailed examination that typically includes a thorough health history and comprehensive head-to-toe physical exam. This type of assessment may be performed by registered nurses for patients admitted to the hospital or in community-based settings such as initial home visits. Advanced practice nurses such as nurse practitioners also perform complete assessments when doing annual physical examinations.
- A problem-focused assessment is an assessment based on certain care goals. For example, a nurse working in the ICU and a nurse that does maternal-child home visits have different patient populations and nursing care goals, she says. These assessments are generally focused on a specific body system such as respiratory or cardiac. While the entire body is important there is usually not enough time for a detailed full-body assessment.
Length of Assessment
Ferere explains that the duration of the exam is directly in correlation 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.”
How to Prepare for the Assessment
“Like all clinical settings, standard precautions (formerly universal precautions) should always be practiced with each and every patient to protect both the nurse and patient,” states Zucchero.
“The primary goal of standard precautions is to prevent the exchange of blood and body fluids and includes hand hygiene, use of personal protective equipment, and safe handling and cleaning of potentially contaminated equipment or surfaces.”
Depending on the type of assessment conducted, the nurse may need specific equipment, states Zucchero.
Basic equipment includes:
- Blood pressure cuff
- Height wall ruler
- Tape measure,
Additional equipment for more comprehensive examinations would include,
- 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)
Beginning An Assessment
When beginning an assessment, Zucchero says, “establishing a personal relationship of trust and respect between the patient and the nurse is vital.” She adds that is it important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable.
She continued, “in addition, it’s important that an assessment is conducted systematically and efficiently to minimize unnecessary touching of the patient.”
“For new nursing graduates and nursing students, a head-to-toe assessment is driven by the needs of the patient, setting of the examination and the relationship with the examiner,” stated Angela Haynes.
“This baseline examination determines knowledge about patient health needs, current health status and patient goals for personal health outcomes, including health promotion and wellness counseling,” she says.
What to look for During an Assessment
Differentiating normal from abnormal is an important skill, Zucchero explains.
Some examples of major abnormal findings are changes in normal respiratory rate that indicates respiratory distress, or a change in skin color such as pallor that may indicate anemia or jaundice that typically indicates liver problems.
Generally, the human body is bilaterally symmetrical. When you are examining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has a limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue.
Building Rapport With the Patient
The nurse must always introduce themselves to the patient, verify they are with the correct patient, and explain what they will be doing, adds Zucchero.
This is a good time to start with a review of paperwork and build a relationship before the physical portion of the exam is started, Ferere says.
It is also the appropriate time to talk about the patient’s personal preferences about undressing for the exam, as well as lighting needs, the temperature of the room and any pain or areas of discomfort.
“The patient may also prefer to have another person in the room for the exam for comfort. This should be allowed when possible. Policies are usually in place to support the presence of a witness for any invasive procedures,” she adds.
Ferere adds that a cooperatively engaged patient visit may not be performed with the same sequence as a combative or confused patient. Engaging the patient early in the visit increases the likelihood that the patient will take more ownership of health status and ongoing health needs.
Pay Close Attention to Nonverbal Cues From the Patient
These cues can include grimacing with ambulation, grunting during movement or when making contact with a body system, Ferere says.
“It may also be an avoidance of eye contact or reluctance to answer questions,” she adds. “The nurse must pay very careful attention to what the patient says and does not say during the visit. Oftentimes, nurses are acting as detectives during patient visits attempting to put together different findings, conversations and health histories.”
Head-to-Toe Assessment Sequence
Ferere says the sequence is based on the examiner’s preference. Usually, it begins with the least invasive to most invasive allowing time for the patient to become more comfortable with the examiner. It also increases the likelihood that the examiner will not forget a system during the exam.
“During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”
The Order of a Head-to-Toe Assessment
1. General Status
- Vital signs
- Heart rate
- Blood pressure
- Pulse oximetry
- Respiratory rate
2. Head, Ears, Eyes, Nose, Throat
- Observe color of lips and moistness
- Inspect teeth and gums
- Assess buccal mucosa and palate
- Examine Tongue
- Examine at uvula
- Examine tonsils
- Palpate nose and assess symmetry
- Check Septum and inside nostrils
- Verify patency of nares
- Check patient’s sense of smell
- Palpate sinuses
- Assess patient hearing with whisper test
- Tuning Fork test (Weber’s test, Rinne test)
- Look inside ear
- Assess ear discharge and tympanic membrane
- Check conjunctive and sclera
- Assess eye symmetry
- Check vision with Snellen Chart
- Check six cardinal positions of the gaze
- Palpate lymph nodes
- Observe and palpate trachea and neck
- Check for Jugular Venous Distention
- Check neck range of motion
- Check shoulder shrug with resistance
- Listen to lung sounds front and back
- Assess respiratory expansion level
- Ask about coughing
- Palpate thorax
- Palpate the carotid and temporal pulses bilaterally
- Listen to heartbeat
- Inspect abdomen
- Listen to 4 quadrants of abdomen for bowel sounds
- Palpate 4 quadrants of abdomen for pain/tenderness
- Ask about problems with bowel or bladder
- Check pulses in arms/legs/feet including,
- Posterior tibial
- Dorsalis pedis
- Assess range of motion and strength in arms/legs/ankles
- Assess sharp and dull sensation on arms/legs
- Check capillary refill on fingernails/toenails
- Check skin turgor
- Check for lesions, abrasions, rashes
- Check for tenderness, lumps, lesions
- Check if patient is pale, clammy, dry, cold, hot, flushed
- Oriented x3
- Assess gait
- Check coordination
- Assess reflexes
- Check Glasgow Coma Scale score
Seek Out Help From Mentors And Colleagues
Ferere adds that new nurses should trust the foundational knowledge obtained in nursing school and seek strong, supporting nursing mentors as resources in health care delivery settings.
“Confidence in assessment continues to grow with every completed assessment. Nurses should not be afraid to ask for help when something does not seem right and rely on your instincts and training,” she says.