How to Perform a Head-to-Toe Assessment
This article describes the basics of a head-to-toe assessment which is a vital aspect of nursing. It should be done each time you encounter a patient for the first time each shift (or visit, for home care, clinic or office nurses).
This assessment includes assessment of the physical, emotional and mental aspects of all body systems as well as the environmental and social issues affecting the patient. The nurse needs to observe for all of these factors and ask questions as needed.
Time Required: Approximately 10-20 minutes
1. Assemble your equipment.
Wash your hands. Greet and identify the patient. Explain what you are going to do. Provide for privacy. Begin with the 5 Vital Signs: Temperature, Pulse, Blood Pressure, Respiration and Pain. Ask the patient how he/she feels and observe the environment. As you assess the body by systems, observe for such tings as non-verbal cues, mobility and ROM.
Head: Shape and symmetry; condition of hair and scalp
Eyes: Conjunctiva and sclera, pupils; reactivity to light and ability to follow your finger or a light
Ears: Hearing aids, pain? Speak in a whisper: can he hear you and comprehend? Turn away to make sure he isn’t reading your lips.
Nose: Drainage, congestion, difficulty breathing, sense of smell
Throat and Mouth: Mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph nodes, tongue
3. Level of Consciousness and Orientation:
Is he awake and alert? Is he oriented to Person (knows his name), Place (he can tell you where he is) and Time (knows the day and date). A fourth level of orientation is Purpose (he knows why you are examining him; or knows the function of something such as your penlight or stethoscope).
As you examine all body systems you need to make note of the status of the Integumentary System for any breaks in the skin, scars, lesions, wounds, redness, or irritation. Assess the turgor, color, temperature and moisture of the skin.