How to Conduct a Head-to-Toe Assessment in Nursing

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Listening to a patient run through a number of symptoms may seem overwhelming — particularly when you’re trying to figure out how you can help ease or eliminate these symptoms. You’ll want to conduct a nursing assessment to help your patient identify the source of their problems and outline possible solutions.

A head-to-toe nursing assessment is key to providing expert care for your patients. This type of assessment helps you gain a more complete understanding of your patient’s current state, as well as the potential reason behind the signs and symptoms they’re experiencing. In addition, the results of this assessment will be relayed to the rest of your patient’s health care team via the care plan you develop. Accuracy is crucial to the well-being of your patient.

In our video and through this article, we will define what a nursing assessment is and walk you through how to conduct one.

What is a head-to-toe 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 what your patient needs. You will look at the function of all the different parts of the body when conducting this type of evaluation. You’ll also assess invisible needs, such as the status of your patient’s mental state and neurological health.

When is a head-to-toe assessment typically performed?

As a nurse, you will generally be the first one in action when it comes to your patient receiving medical treatment interventions. To begin, you’ll want to perform a complete health assessment to best understand your patient’s needs, and to effectively pass this information along in your nursing report sheet.

Some instances where you would need to conduct a nursing assessment include:

  • If a patient needs to be seen in the emergency room, an ER nurse will administer a head-to-toe assessment to ensure their records contain the most accurate information regarding their health history.
  • If you are a nurse practitioner giving annual physical examinations, you might use a head-to-toe assessment to gain a complete picture of the patient’s health each year.
  • Keeping a regular file 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.

nurse with patient

How to conduct a head-to-toe nurse 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).

Initial assessment

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. This part of the assessment helps determine why the patient has come to the exam room and 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 whether they seem dressed appropriately, how their hand-hygiene is, and their basic posture
  • Initial information about pain they experience, or their health history: Where is the pain located? How severe? Is this pain new?

Vital signs

During the next phase of the assessment, you will ask the patient if you can perform a physical exam and record their vital signs. Vital signs register how well the body is performing basic functions. They’re used to tell you and the doctors you work with things that the patient likely cannot.

Some common vital signs include:

  • Heart rate
  • Temperature
  • Respiratory rate
  • Blood pressure
  • Pulse rate

Hair/skin/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 phase include:

  • Nails: signs of delayed capillary refill, clubbing, or fungus
  • 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

You will want to examine the head for discomfort or abnormalities.

Things to look for during the head assessment phase include:

  • Using your hands and eyes to check for any signs of asymmetry, tenderness, or edema
  • Inquiring about any pain or discomfort
  • Examining the facial nerve by asking the patient to smile and raise their eyebrows

Neck

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.

Areas to pay attention to while assessing the neck include:

  • Seeing if the patient’s spinal accessory nerve demonstrates any abnormalities by asking the patient to shrug their shoulders
  • Looking for signs of a limited range of motion in the neck by having the patient rotate their head in various directions
  • Looking for signs of swelling or enlarged lymph nodes or glands
  • Assessing the patient for signs of deviation of the trachea
  • Noting any signs of an enlarged thyroid gland

Eyes

You will also closely examine the patient’s eyes for potential symptoms.

Areas to check for while examining the eyes include:

  • The sclera, looking for any signs of discharge, redness, lesions, or other abnormalities
  • Checking for Pupils Equal Round Reactive to Light and Accommodation (PERRLA) to make sure they respond appropriately
  • Having the patient move their eyes around to check the cranial nerves
  • Using a visual acuity test to see how the optic nerve performs

Nose/sinus

An examination of the nose and sinus function can help you check for issues with the sense of 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
  • Using your fingers to palpate the sinuses for tenderness
  • Inspecting the septum
  • Using scented objects to test the olfactory nerve
  • Checking for signs of discharge or nasal polyps

Ears

Examining the ears calls for assessing this part of the body both inside and out.

Recommendations for assessing the ears holistically include:

  • Using a whisper test to see how the patient’s vestibulocochlear nerve performs
  • Seeing how the ear looks on the outside, including using an otoscope to check for signs of light reflecting abnormally from the inside
  • Looking for signs of lesions or discharge, including any inner scarring

Mouth/throat

Ask your patient to open their mouth for a close examination of the mouth and throat.

When examining the mouth and throat, things you’ll want to look for include:

  • Signs of swelling of the lips, tonsils, uvula, or elsewhere in the mouth
  • Lesions or other abnormalities throughout the mouth and throat
  • Cracked or dried lips or other signs of dryness
  • A hairy tongue
  • Any trouble tasting foods, swallowing, or gagging

Chest

The chest area can provide valuable insight into the patient’s respiratory and cardiovascular health.

Areas to pay attention to when assessing the chest include:

  • Checking for heart sounds that indicate an abnormal heartbeat, such as a murmur
  • Checking for the apical pulse
  • Listening to the lung sounds made by the diaphragm; checking for abnormalities with the stethoscope in the different sections of the heart
  • Gauging if the patient seems to have labored breathing or is gasping for air by listening to their breath sounds
  • Listening for signs of crackles or wheezing by listening to their lung sounds
  • Looking for abnormal findings, such as intercostal retractions

Abdomen

To complete a physical assessment of the abdomen, you will need to use your hands for a light palpation and your eyes to check for signs of distress or abnormalities.

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
  • Seeing if the abdomen pulsates as expected
  • Inquiring about signs of gastrointestinal health, such as abnormal bowel movements

Pulses and vascular

The patient’s pulses can provide you with valuable information about their overall health. There are four different pulses you can take: radial pulses, femoral pulses, posterior tibial pulses, and dorsalis pedis pulses.

Things to look for when assessing the veins and pulses include:

  • Looking for absent pulses in different areas
  • Seeing if you observe any signs of arterial or venous disease
  • Looking for skin discolorations
  • Checking for signs that the capillaries are not refilling properly

Extremities and the musculoskeletal system

To check if the patient has any troubles with their extremities, you will need to assess the function and appearance of their arms, legs, and ankles.

An extremity and musculoskeletal system assessment will likely include:

  • Seeing if the patient has any trouble moving around their upper or lower extremities
  • Checking the patient’s strength in the various extremities
  • Examining the patient to see if they can identify sharp and dull sensations on their extremities
  • Looking for signs of abnormalities in the fingernails and toenails

Neurological

You also need to closely examine the patient’s mental state for signs of delay or confusion.

Things to pay attention to when examining the neurological state include:

  • Examining the patient’s balance
  • Looking at the patient’s gait by having them walk across the room heel to toe
  • Seeing how the patient’s reflexes work

nurse and old patient

See how SimpleNursing makes studying for nursing school easy

Learning how to do a complete head-to-toe assessment 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 patients’ health.

If you want to continue to excel in nursing school, you also need to prepare for important nursing exams like the NCLEX. SimpleNursing has set out to create all of the resources you need to conveniently study for any upcoming nursing examinations. Learn more to see what we can offer you as a nursing student.