Head-To-Toe Assessment Guide

 A head to toe assessment is an exhaustive process that checks the health status of all major body systems.
It is a comprehensive physical examination that shines a light on a patient’s needs and problems.

Equipment Needed For Head To Toe Assessment
>Gloves
>Thermometer
>Scale
>Hight wall ruler
>Penlight
>Stethoscope
>Blood pressure cuff
>Tongue depressor
>Sterile objects, both soft and sharp

The first thing you need to do before starting an assessment per se is to build rapport with the patient

Methods Used for Head to Toe assessment

1.Inspection
Always performed first, inspection also is the most repeated method of examination.
2.Palpation
Touching the patient to sense abnormalities on (or in) the body is known as palpation.
3.Percussion
This third technique requires the nurse to tap on the patient’s body to produce sound vibrations
4.Auscultation
The last method of examination is auscultation. It implies listening to the heart, lungs, neck, or abdomen to gather information

Head to Toe Assessment Checklist

1.General Overview
>First, you obtain a general overview of the patient’s health state.
 -Take vital signs
-Check heart rate
-Measure blood pressure
-Take body temperature
-Pulse oximetry
-Respiratory rate
-Check pain levels
-Check height and weight and calculate their BMI

2. Hair

 Skin/ Nails
>Once you have a general overview, you can start from the top of the body and make your way down.

3. Head
>Shape is rounded, symmetrical
Upon palpation, no nodules, masses or depressions are identified
Face appears smooth and symmetrical with no nodules or masses present.

4. Eyes
>Check external structures
Assess eye symmetry
Check conjunctive and sclera
Check for PERRLA

5. Nose
>Palpate nose and check symmetry
Check septum and inside nostrils

6. Mouth and Throat
>Check lips for color and moistness
Inspect teeth and gums

7. Ears
>Inspect for drainage or abnormalities
Test hearing with whisper test

8. Neck
>Check neck muscles to be equal in size
Palpate lymph nodes

9. Chest: Cardiovascular Assessment
>Listen to the heartbeat. Areas where to auscultate heart sounds

10. Chest: Respiratory Assessment
>Auscultate lung sounds front and back

11. Abdomen
>Inspect abdomen
Listen to bowel sounds in all four quadrants

12. Extremities
>Assess range of motion and strength in arms, legs, and ankles
Assess sharp and dull sensation on arms and legs

13. Back area
>Inspect back and spine
Inspect coccyx/buttocks

Key Points during Head-to-Toe Assessment
1. Document your findings
2. Communicate efficiently
3. Bilateral symmetry