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- What is a head-to-toe nursing assessment?
- How to Conduct a Head-to-Toe Nursing Assessment
- Head to Toe Assessment Checklist
Listening to a patient verbalize multiple symptoms may seem overwhelming — particularly when you don’t know the exact diagnosis. The first step in the nursing process is assessment.
This type of assessment helps the nurse gain a more complete understanding of the patient’s current state and the potential reason behind the signs and symptoms they’re experiencing.
In addition, the results of this assessment will be relayed to the health care provider (HCP) and will allow the nurse to create a nursing care plan that will guide the patient’s care. Therefore, accuracy is crucial to the well-being of your patient.
What is a head-to-toe nursing assessment?
A head-to-toe assessment is a health evaluation that a nurse administers to better understand a patient’s status. As a nurse, this process helps you better understand your patient’s needs.
The assessment encompasses every body system and the patient’s mental and neurological needs.
When is a head-to-toe assessment typically performed?
As a nurse, you are most likely the patient’s first encounter with a health care individual when they are seeking medical treatment. To begin, you’ll want to perform a complete health assessment to understand your patient’s needs best, and to pass this information along in your nursing hand-off report effectively.
Some instances where you would need to conduct a nursing assessment include:
- When a patient presents to the emergency room/department (ER/ED), the Registered nurse will conduct a head-to-toe assessment to ensure the patient’s records contain the most accurate information regarding their health history.
- When a patient is admitted to a hospital unit, a Registered nurse is responsible for the initial assessment and assessments per shift to assess for any changes.
- If you are a nurse practitioner (NP) conducting physical examinations, the head-to-toe assessment will assist the NP in making a proper diagnosis for treatment of the patient.
- Keeping accurate updates of head-to-toe assessments helps pediatric nurses understand the year-over-year development of the children they work with, and helps geriatric nurses understand the improvement or decline in the health of the patients they see and treat.
How to Conduct a Head-to-Toe Nursing Assessment
Now that you know what a nursing assessment is and when to use this process, we will walk you through how to conduct your head-to-toe nursing assessment (including what to look for during each phase).
Your initial assessment involves everything you notice about the patient as soon as you walk into the exam room, including both subjective and objective observations. The first interaction portion of the assessment can help determine the patient’s chief complaint along with their mental status.
Things to look for during the initial assessment include:
- Whether the patient appears alert, greets you, and answers questions appropriately
- Signs of patient distress, including labored breathing and/or confusion
- Overall appearance, including if they seem dressed appropriately, their basic hygiene, and their posture.
- Overall health history
- Initial information about pain using the mnemonic PQRST:
- Precipitating factors (what causes the pain)
- Quality (throbbing, aching, stabbing)
- Region or radiating
- Severity (pain scale 1-10)
- Time (when did it begin?, how long does it last?)
During the next assessment phase, you will ask the patient if you can take their vital signs and perform a physical exam. Vital signs register how well the body is performing basic functions. Vital signs are vital to life. They are used to show how the body is functioning.
Some common vital signs include:
- Heart rate
- Respiratory rate
- Blood pressure
- Pulse rate
- Oxygen saturation
- Pain level
Hair, Skin, and Nails
As you begin to examine the patient carefully, look for and note signs and symptoms related to the patient’s hair, skin, and nails. These notes can tell you quite a bit about their overall health.
Areas to pay attention to during the hair, skin, and nails assessment include:
- Nails: signs of delayed capillary refill, > 3 seconds, clubbing, or fungus of the nail beds
- Hair: signs of uneven hair distribution
- Skin: checking for rashes; changes in skin color, such as pallor or erythema; signs of decreased skin turgor or lesions; checking for hot or moist skin
Head to Toe Assessment Checklist
You will want to examine the head for discomfort or abnormalities.
Things to look for during the head assessment include:
- Inspection with your eyes to check for any signs of asymmetry, or edema
- Inquiring about any pain or discomfort
- Examining the facial nerve by asking the patient to smile and raise their eyebrows
- Touching (palpation) for any tenderness or edema
Use your eyes to visually examine the patient’s neck, and use your hands to carefully palpate the area to look for any signs or symptoms.
Assessment of the neck should include:
- Assessment of the patient’s spinal accessory nerve while asking the patient to shrug their shoulders. Abnormalities can be found during this assessment.
- Inspecting any limited range of motion in the neck by having the patient rotate their head in various directions
- Palpating the neck for swelling or enlarged lymph nodes or glands
- Inspection of the patient‘s neck for a tracheal deviation.
- Noting any signs of an enlarged thyroid gland by palpating while the patient swallows some water.
Assessment of the eyes include:
- Inspecting the sclera, assessing for signs of discharge, redness, lesions, or other abnormalities
- Inspection of the pupils with a pen light to check the pupillary response to light and movement. (PERRLA=pupils equal, round, reactive to light and accommodation) Also noting the size of the pupils as well.
- Inspection of the patient’s six extraocular eye muscles to determine how well they are working along with cranial nerves, III, IV, and VI.
- Using a visual acuity test to see how the optic nerve performs
Nose and Sinus
Examining the nose and sinuses can assess any issues with smell, potential sinus infections, or other damage to the area.
Tips for examining the nose and sinus area include:
- Using your otoscope to examine the inside of the nose also while Inspecting the septum
- Palpate the sinuses for tenderness
- Use scented objects to test the olfactory nerve for smell
- Checking for signs of discharge or nasal polyps
Recommendations for assessing the ears include:
- Inspection of the outer and inner ear
- Palpate for any tenderness
- Utilize an otoscope to assess the cone of light
- Assess for signs of lesions, discharge, bulging, or any inner scarring
- Perform the whisper test to see the function of the vestibulocochlear nerve
Mouth and Throat
Ask your patient to open their mouth to closely examine the mouth and throat.
Upon examination of the throat and mouth, inspect the following:
- Signs of swelling of the lips, tonsils, uvula, or elsewhere in the mouth
- Lesions or other abnormalities of the mucosa
- Cracked or dried lips or other signs of dryness
- A hairy tongue
- Ask the patient if they have had any difficulty with tasting foods, swallowing, or gagging.
The chest area can provide valuable insight into the patient’s respiratory and cardiovascular health.
Assessment of the cardiovascular and respiratory system includes:
- Inspect any visual chest defects.
- Auscultate heart sounds that indicate an abnormal heartbeat, such as a murmur.
- Auscultate the apical pulse at the point of maximum impulse.
- Auscultate lung sounds in all fields (anterior, posterior, and lateral), listening for normal vs abnormal breath sounds. Be aware of crackles, wheezes, stridor.
- Inspect the rise and fall of the chest. Looking for abnormal findings, such as intercostal retractions. (Are the respirations labored?)
To assess the abdomen properly, you must first inspect. Next, you will auscultate before any palpation or percussion to avoid disturbing bowel sounds. If the patient is experiencing abdominal pain, they will guard the abdomen, and likely you will not get a chance to auscultate.
Tips for examining the abdomen include:
- Looking for new or differing skin pigmentation.
- Checking for tenderness.
- Looking for any signs of protrusions.
- Using auscultation to see if you hear abnormal bowel sounds in any of the four abdominal quadrants. If no bowel sounds are present, you must auscultate all four abdominal quadrants for five minutes each before charting no bowel sounds.
- Inspecting any abdominal pulsations.
- Inquiring about signs of gastrointestinal health, such as abnormal bowel movements, as well as the last bowel movement.
Pulses and Vascular
The patient’s pulses can provide valuable information about overall health. The following pulses should be assessed (palpated ) in a head to toe assessment: temporal, carotid, apical (with cardiac), brachial, radial, femoral, popliteal, posterior tibial, and dorsalis pedis pulse.
Things to look for when assessing the veins and pulses include:
- Palpating and document pulses. Prompt intervention for absent pulses.
- Observing any signs of arterial or venous disease
- Inspecting the skin for discolorations
- Checking for signs that the capillaries are not refilling properly
Extremities and the Musculoskeletal System
Assessment of the musculoskeletal system involves a range of motion (active or passive) and strength of extremities.
An extremity and musculoskeletal system assessment will likely include:
- Assessment of difficulty independently moving upper or lower extremities.
- Assessment of strength in the upper and lower extremities.
- Examining the patient to see if they can identify sharp and dull sensations on their extremities
- Inspecting signs of abnormalities in the fingernails and toenails
You also need to closely examine the patient’s mental state for signs of delay or confusion.
Assessment of the neurological state includes:
- Inspecting the patient’s balance
- Assessing the patient”s gait while having them walk across the room heel to toe
- Testing the patient’s reflexes for normal vs abnormal findings.
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Learning how to complete head-to-toe assessments will help you perform better as a future nurse or nursing student. Taking this holistic look at the individual by examining all body systems can help you spot potential problems and gain a complete picture of your patient’s health.
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