Nursing Head-to-Toe Assessment Guidelines

Jan 21, 2025

Nursing Head-to-Toe Assessment

Introduction

  • Head-to-toe assessment is similar to clinical checkoff in nursing school.
  • Assess each system in a sequence: Inspect, Palpate, Percuss, and Auscultate.
  • Exception for the abdomen: Inspect, Auscultate, Percuss, and Palpate.

Preliminary Steps

  • Perform hand hygiene and provide privacy.
  • Introduce yourself and explain the procedure to the patient.
  • Verify patient identity using armbands and questions.
  • Check patient alertness and orientation (person, place, time, event).

Collecting Vital Signs

  • Measure heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, and pain rating.
  • Collect height, weight, and calculate BMI.
  • Observe the patient’s response, emotional status, age appearance, skin color, and hygiene.

Head Assessment

  • Inspect: Skin color, head symmetry, abnormal movements.
  • Palpate: Check for masses, indentations, skin breakdown, infestations.
  • Cranial Nerve 7 Test (Facial): Facial expressions.

Eye Assessment

  • Inspect: Eyelid, sclera, iris, pupil, conjunctiva.
  • Cranial Nerves 3, 4, 6 Tests: Six cardinal fields of gaze, pupil reaction to light, accommodation test.

Ear Assessment

  • Inspect & Palpate: Check for abnormalities, pain, and tenderness.
  • Cranial Nerve 8 Test (Vestibulocochlear): Whisper test.
  • Otoscope Inspection: Tympanic membrane check.

Nose Assessment

  • Inspect: Nose symmetry, septum, patency, drainage.
  • Cranial Nerve 1 Test (Olfactory): Smell test.

Mouth and Throat Assessment

  • Inspect: Lips, inside of the mouth, gums, teeth, palates.
  • Cranial Nerves 9, 10, 12 Tests: Tongue movement, gag reflex, talking, and swallowing.

Neck Assessment

  • Inspect & Palpate: Trachea, lesions, lumps, JVD.
  • Cranial Nerve 11 Test (Accessory): Head movement, shoulder shrugging.
  • Lymph nodes assessment.
  • Carotid Artery: Palpate and auscultate for bruits.

Upper Extremity Assessment

  • Inspect & Palpate: Swelling, lesions, IV sites, pulses.
  • Check: Capillary refill, skin turgor, muscle strength, joint motion.

Chest Assessment

  • Inspect: Breathing effort, chest diameter.
  • Auscultate Heart Sounds: Aortic, pulmonic, Erb’s point, tricuspid, mitral valves.
  • Auscultate Lung Sounds: Check anteriorly and posteriorly for abnormalities.

Abdominal Assessment

  • Inspect: Contour, pulsations, wounds, ostomy sites.
  • Auscultate: Bowel sounds, vascular sounds.
  • Palpate: Light and deep palpation for pain, tenderness, masses.

Lower Extremity Assessment

  • Inspect: Skin color, hair growth, swelling.
  • Palpate: Pulses, edema.
  • Function Tests: Muscle strength, Babinski reflex.

Back Assessment

  • Inspect: Moles, lesions, skin breakdown.
  • Lung Sounds: Listen posteriorly if not done earlier.

Conclusion

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