How to Conduct a Nursing Head-to-Toe Assessment

A head-to-toe assessment is a physical examination or health assessment, and it is one of the many important components of understanding a patient’s needs and problems. This assessment is performed during every shift and sometimes multiple times to determine if there have been any changes in your patient’s status. 

We've put together a step-by-step guide to what happens in a nursing head-to-toe assessment and how nurses should understand the physical, emotional, and mental aspects of someone’s body systems.

Head-to-Toe Assessment 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 in Boston, and Angela Haynes Ferere, DNP, FNP-BC, MPH, serves as the DABSN Program Director at Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.

What is a Head-to-Toe Assessment?

A head-to-toe assessment is an evaluation of all the body's systems to give you a picture of the patient's health needs and problems. “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,” Zucchero says. 

There are several types of assessments that can be performed:

1. Complete Health Assessment 

A complete health assessment is a detailed examination that typically includes a thorough health history and a 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 registered nurses (APRN) such as nurse practitioners (NP) also perform complete assessments when doing annual physical examinations.

2. Problem-Focused Assessment

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. 

How to Conduct a Head-to-Toe Assessment

Step 1: Establish Trust

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 it is important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable. You'll want to introduce yourself to the patient and explain the assessment process

Step 2: Confirm the patient’s ID

Step 3: Note The patient's Appearance and Status

“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.”

Step 4: Assess the ABCs

Prior to starting a detailed assessment, you'll want to assess the ABCs  - airway, breathing, and circulation.

Usually, the assessment 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.  

Step 5: Look for Abnormalities

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.

The Order of a Head-to-Toe Assessment

Assessment Area	Assessment Tasks
General Status Vital signs  Heart rate Blood pressure Temperature Pulse oximetry Respiratory rate Pain Height/Weight/BMI	Assess pain using the appropriate pain scale for the patient Numerical Scale Wong-Baker Faces Pain Scale FLACC Pain Scale CRIES Pain Scale COMFORT Pain Scale McGill Pain Questionnaire Color Analog Pain Scale
Head, Ears, Eyes, Nose, Throat (HEENT) Inspect head tilt Inspect skull and scalp Inspect facial features Palpate head and scalp Auscultate temporal arteries if appropriate Inspect  the color of lips and moistness Inspect teeth and gums Inspect  buccal mucosa and palate Inspect  Tongue Inspect  at uvula Inspect  tonsils Palpate nose and assess symmetry Inspect septum and inside nostrils Inspect  patency of nares Inspect  patient’s sense of smell Palpate sinuses Perform whisper test Perform tuning Fork test (Weber’s test, Rinne test) Inspect  ear discharge and tympanic membrane Inspect  conjunctiva and sclera Inspect  eye symmetry PERRLA Check vision with Snellen Chart including distant visual acuity and near visual acuity. Check six cardinal positions of the gaze Inspect the external auditory canal Inspect the tympanic membrane Check for size, shape, symmetry, lesions, trauma	Check for thickening, hardness, and tenderness Observe for masses, webbing, and skinfolds
Neck Palpate lymph nodes Parotid and retropharyngeal (tonsillar) Submandibular Submental Sublingual (facial) Superficial anterior Cervical Superficial posterior cervical Preauricular and postauricular  Sternocleidomastoid Occipital Supraclavicular Inspect and palpate trachea and neck Inspect for Jugular Venous Distention Inspect neck range of motion Inspect shoulder shrug with resistance	Check for symmetry, tenderness, shape Check thyroid for size, shape, configuration, tenderness, nodules
Respiratory  Inspect the chest Perform direct and indirect percussion on the chest Auscultate lung sounds posteriorly and anteriorly Inspect respiratory expansion level Ask about coughing Palpate thorax Inspect nasal flaring and pursed lip breathing Inspect configuration Palpate for tenderness and sensation Palpate for crepitus and fremitus Percuss for diaphragmatic excursion Percuss for tone	Inspect chest for size, shape, symmetry, color, superficial venous patterns, and prominence of ribs Evaluate respirations for rate and rhythm Auscultate for intensity, pitch, duration, and quality of breath sounds
Cardiac Palpate the carotid and temporal pulses bilaterally Auscultate the five areas of the heart  Inspect the precordium  Palpate apical pulse	Assess for murmurs Listen for heart rate, rhythm, S1 and S2
Abdomen Inspect abdomen Auscultate 4 quadrants of the abdomen for bowel sounds Palpate 4 quadrants of the abdomen for pain/tenderness Percuss the 4 quadrants of the abdomen Ask about problems with bowel or bladder Inspect umbilicus Inspect for aortic pulsations and peristaltic waves Palpate the umbilicus and surrounding area for swellings, bulges, or masses	Inspect skin characteristics, venous patterns, symmetry, surface motion Inspect masses, hernia, separation of the muscles Listen for bruits Check for tone, liver borders
Pulses Palpate pulses in arms/legs/feet including, Brachial (in infants) Radial Femoral Posterior tibial Dorsalis pedis	Ensure pulse are palpable and present
Extremities Assess range of motion and strength in arms/legs/ankles Assess sharp and dull sensation on arms/legs Perform capillary refill on fingernails/toenails Palpate each joint in the hand and write Test for carpal tunnel syndrome by performing Phalen’s test	Inspect  for muscle tone, warmth, tenderness, swelling, and crepitus Inspect  for alignment, size, deformities, contour and symmetry
Skin Inspect skin turgor Inspect  for lesions, abrasions, rashes Inspect  for tenderness, lumps, lesions Inspect  if the patient is pale, clammy, dry, cold, hot, flushed	Inspect  for moisture, temperature, texture, turgor, elasticity Inspect  for color, distribution, density Identify pigmentation, length, redness, swelling, pain, growths
Neurological Test cranial nerves I through XII CN I - Olfactory CN II - Optic CN III - Oculomotor CN IV -Trochlear CN V - Trigeminal CN VI - Abducens CN VII - Facial CN VIII - Acoustic/Vestibulocochlear CN IX - Glossopharyngeal CN X - Vagus CN XI - Spinal Accessory CN XII - Hypoglossal Evaluate balance using the Romberg test Evaluate coordination and fine motor skills Test primary sensory responses Oriented x3 Assess gait Assess superficial and deep tendon reflexes Check the Glasgow Coma Scale score	Gait: posture, rhythm, sequence of stride and arm movements Inspect for superficial touch and superficial pain response
Genitalia (this will vary on patient) Palpate inguinal lymph nodes Inspect labia majora, labia minora, clitoris, urethral meatus, and vaginal opening Inspect the base of the penis and pubic hair Inspect the skin of the shaft Palpate the shaft Inspect the foreskin and glans Inspect the size, shape, and position of scrotum Palpate the scrotum Inspect for inguinal or femoral hernia

How to Prepare for Head-to-Toe Assessments

“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.”

Techniques Used During Physical Assessment

There are four techniques utilized during a physical assessment including, inspection, palpation, percussion, and auscultation. It’s important to note that not all four techniques will be utilized during every assessment. 

For example, APRNs will regularly palpate during an exam; however, a bedside med-surg nurse may not have a reason to. It is important that nursing students and nurses know each technique, how to utilize them, when to use them, and why they are important. 

Inspection

This is the first technique used in any assessment. You will want to fully inspect your patient before completing other aspects of the physical assessment. Utilize visual examination to inspect different areas of the body. You will want to note the overall appearance and color. 

Palpation

This is the act of touching a patient to determine abnormalities on or in the body. There are two different techniques used for palpation: light and deep palpation. 

Light palpation is gentle and gives information about skin texture and moisture, fluids, muscle guarding, and some superficial tenderness the patient may be experiencing. 

Deep palpation explores the internal structures of the body to a depth of four to five centimeters. 

Percussion

Nurses will palpate different body parts for sound vibrations. The most common is palpating the abdomen. Palpation can confirm the presence of air, fluid, and/or solids. It also is utilized to determine organ size, shape, and position. 

Auscultation

The final method used during a physical assessment is auscultation, or listening with a stethoscope to the different body systems of your patient. You will want to listen for lung sounds, heart sounds, and bowel sounds. APRNs can also be expected to listen to the neck for bruits. 

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.” 

FAQs

• What 4 techniques are used in a head-to-toe assessment?

  • The four techniques that are used for physical assessment are inspection, palpation, percussion, and auscultation.

• How do you do a head-to-toe assessment?

  • To perform a thorough head-to-toe assessment, it is recommended that you start with an overall inspection of the patient and then move to the head, ears, eyes, nose and throat. Then, move your way down the body systematically. You will need to include the four techniques of inspection, palpation, percussion, and auscultation throughout the assessment.

• What is the purpose of a head-to-toe assessment?

  • The purpose of a head-to-toe assessment is to get a baseline understanding of your patient. This assessment can be used in case there is an emergency or a change in their physical or emotional behavior. It also can be used to help diagnose a disease or illness. 

• What should the nurse begin by assessing when performing a head-to-toe assessment?

  • This will depend on the patient. Typically, the first thing a nurse should do is look or inspect. Use your eyes to look at your patient’s skin, breathing, and outward appearance before moving on to more invasive aspects of the assessment. However, it is best to start at the head for a systematic top-to-bottom approach. 

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.