Introduction to the Head to Toe Assessment
A head to toe assessment is a comprehensive examination of a client’s body. It is used to discover possible signs and symptoms of disease or injury and monitor an individual’s health over time.
Head to toe assessments are a critical component of nursing. This provides clues on clients’ health status, and can help point out any potential issues. The nursing assessment is composed of inspection, palpation, percussion, and auscultation.
Assessment of the client also includes laboratory and diagnostic data; Here are some normal values to remember:
- Sodium (Na+) – 135-145 mEq/L
- Potassium (K+) – 3.5-5.0 mEq/L
- Chloride (Cl-) – 97-107
- Carbon Dioxide (CO2) – 23-29 (mEq/L)
- Bicarbonate (HCO3) – 23-30 mEq/L
- BUN – 10-20
- Glucose – 70-110
- Calcium (Ca) – 9.0-10.5 mEq/L
- Magnesium (Mg+) – 1.3 – 2.1 mEq/L
- Hemoglobin – 12-18
- Hematocrit – 36-54%
- Red blood cell count (RBC) – 4-6 million
- WBC Total Count – 5,000-10,000
- CD4 Count – Over 200
- Platelets – 150k – 400k
- PTT – 30-40
- INR – 0.9-1.2
Head to Toe Assessment Checklist
- A general overview (checking for signs of illness)
- The head (eyes, ears, nose, and mouth)
- The neck (blood pressure and pulse)
- The chest (lungs)
- The abdomen (organs and other vital signs)
- Extremities (arms and legs)
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Normal Range Vitals
The client assessment begins with vital signs. Knowing normal values will help the nurse determine the abnormal. When examining a client’s vitals, you’ll be able to determine whether or not any of their bodily systems are functioning within the normal range:
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg.
- Breathing: 12 to 18 breaths per minute.
- Pulse: 60 to 100 beats per minute.
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
When assessing circulation, think about how well the client’s blood is flowing through their body. If circulation appears to be an issue, check for swelling or redness in the legs and arms. Remember to also check for numbness and any changes in color on those parts of the body.
Is the client experiencing tingling in the hands? Is the client’s feet cold? Is the skin pale or flushed? These are all signs that your client’s circulation isn’t working as well as it could be.
Assessment of the circulatory system includes:
- Blood pressure
- Pulse rate
- Respiratory rate
- Auscultating heart sounds
Capillary refill is an important part of the head to toe assessment. It is a quick way for nurses to understand how well the client is hydrated. Signs of shock can be assessed with capillary refill and thus an important part of the head to toe assessment.
Skin Turgor Assessment
Turgor is the elasticity of the skin, which can be described as “taut” or “glassy.” A skin turgor assessment aims to determine how much pressure it takes to depress the skin. It’s measured by pinching the skin on the back of the hand, and then releasing it.
Skin turgor is best tested over the back of the hand, on the abdomen, or over the front of the chest under the collarbone. If the skin springs back within one second, it’s considered normal. If it takes longer than two seconds, it could indicate dehydration.
When assessing the client’s skin the nurse will check for body color, temperature, moisture as well as redness or swelling in the client’s extremities. Signs of warmth could indicate an infection. Signs of bruising or discoloration should be considered as well as the integrity of the skin (e.g., ulcers, sores, pressure wounds, tears).
Head & Neck Assessment
This assessment is important because it can reveal other concerns. For example, if you notice that the client is having trouble swallowing or has tenderness around the ear, this could indicate an issue with their esophagus or thyroid gland.
The head and neck portion of a head to toe assessment includes:
- Hair (color, texture, amount)
- Scalp (color, texture, amount)
- Eyes (color, shape, movement, presence or absence of tears)
- Pupils (size and reaction to light)
- Nose (shape, color, and size of nostrils)
- Mouth (lips, teeth, and tongue)
This portion of the head to toe assessment includes several steps that are broken down into three major categories: inspection, palpation, and percussion.
Inspection includes looking at the client’s chest and observing any rashes or abnormalities. Palpation involves feeling the client’s chest with your hands and noting any unusual lumps or bumps that are present.
Percussion is where you tap on various chest areas with your hand until you find a hollow-sounding spot, indicating an air space within the lung. Auscultation involves listening to the client’s lungs with a stethoscope.
The abdomen is one of the most important parts of the body to assess during a head to toe assessment. It indicates how well a client’s body absorbs nutrients and processes waste.
The four steps of assessment change with the abdomen. Inspect, then auscultate as to not disturb the digestive tract.
In the case of abdominal pain, once you begin palpating, the client is unlikely to allow auscultation. During palpation the nurse will assess for tenderness and swelling. Don’t forget to include these items in the abdominal assessment.
- Digestive system – Is the client vomiting or having diarrhea? These symptoms could indicate a problem with their digestive system. Are they constipated? This could be due to dehydration or other issues.
- Liver – Is there abdominal distention? You should be able to feel four fingers between your hand and your client’s abdomen if they’re eating normally. If it feels like there’s less space between them than that, you may want to consider calling a doctor.
- Gallbladder – Does your client experience pain in their lower right quadrant? This could mean that their gallbladder isn’t functioning properly.
During my exam, I could literally see and hear him going over different areas as I was answering my questions.
This past Friday I retook my Maternity Hesi and this time, I decided for my last week of Holiday break to just watch all of his OB videos. I am proud to say that with Mike’s help I received a score of 928 on my Maternity Hesi!
Conclusion to Head to Toe Assessments
Head to toe assessments are crucial to identifying the health status of a client.It is important for the nurse to inspect, palpate, percuss and auscultate during the physical assessment. Being aware of the normal ensures the nurse can identify the abnormal and report any findings to the health care provider (HCP) for intervention.