April 12, 2024

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How to Conduct a Head-To-Toe Assessment Nursing

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How to Conduct a Head-To-Toe Assessment Nursing

A head-to-toe assessment is a physical examination or health assessment, and it is one of the many important components of understanding a patient’s needs and problems. This assessment is performed during every shift and sometimes multiple times to determine if there have been any changes in your patient’s status. 

We’ve put together a step-by-step guide to what happens in a nursing head-to-toe assessment and how nurses should understand the physical, emotional and mental aspects of someone’s body systems.

Head-to-Toe Assessment Experts

We interviewed two healthcare experts to learn their best practices for conducting head-to-toe assessments. Terri Zucchero PhD, RN, FNP-BC is a nurse practitioner in Boston and Angela Haynes Ferere, DNP, FNP-BC, MPH, serves as DABSN Program Director at Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.

This article has also been reviewed by our panel of experienced registered nurses:

  • Tyler Faust, MSN, RN
  • Chaunie Brusie, BSN, RN
  • Kathleen Gaines, MSN, RN, BA, CBC

 >> Click to See the 4 Steps to Becoming an Aesthetic Nurse

A head-to-toe assessment is an evaluation of all the body’s systems to give you a picture of the patient’s health needs and problems. “This baseline examination determines knowledge about patient health needs, current health status and patient goals for personal health outcomes, including health promotion and wellness counseling,” Zucchero says. 

There are several types of assessments that can be performed.

Complete Health Assessment 

A complete health assessment is a detailed examination that typically includes a thorough health history and a comprehensive head-to-toe physical exam. This type of assessment may be performed by registered nurses for patients admitted to the hospital or in community-based settings such as initial home visits. Advanced practice registered nurses (APRN) such as nurse practitioners (NP) also perform complete assessments when doing annual physical examinations.

Problem-Focused Assessment

A problem-focused assessment is an assessment based on certain care goals. For example, a nurse working in the ICU and a nurse that does maternal-child home visits have different patient populations and nursing care goals, she says. These assessments are generally focused on a specific body system such as respiratory or cardiac. While the entire body is important there is usually not enough time for a detailed full-body assessment. 

Ferere explains that the duration of the exam is directly correlated to the patient’s overall health status.

“Health patients with limited health histories may be completed in less than 30 minutes,” she says. “Many health practices have patients complete health history and pre-visit forms prior to presentation for a comprehensive visit. Review of these forms in advance can certainly reduce the required visit time.” 

“Like all clinical settings, standard precautions (formerly universal precautions) should always be practiced with each and every patient to protect both the nurse and patient,” states Zucchero. “The primary goal of standard precautions is to prevent the exchange of blood and body fluids and includes hand hygiene, use of personal protective equipment, and safe handling and cleaning of potentially contaminated equipment or surfaces.”

Depending on the type of assessment conducted, the nurse may need specific equipment. 

Basic equipment includes:

  •  Gloves 
  • Thermometer
  • Blood pressure cuff
  • Watch
  • Scale
  • Height wall ruler
  • Tape measure, 
  • Penlight
  • Stethoscope

Additional equipment for more comprehensive examinations would include,

  •  Otoscope
  • Ophthalmoscope
  • Reflex hammer
  • Tongue depressor
  • Sterile sharp object (like toothpick or pin)
  • Sterile soft object (like cotton ball)
  • Something for the patient to smell (like an alcohol swab)

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There are four techniques utilized during a physical assessment including, inspection, palpation, percussion, and auscultation. It’s important to note that not all four techniques will be utilized during every assessment. 

For example, APRNs will regularly palpate during an exam; however, a bedside med-surg nurse may not have a reason to. It is important that nursing students and nurses know each technique, how to utilize them, when to use them, and why they are important. 

Inspection

This is the first technique used in any assessment. You will want to fully inspect your patient before completing other aspects of the physical assessment. Utilize visual examination to inspect different areas of the body. You will want to note the overall appearance and color. 

Palpation

This is the act of touching a patient to determine abnormalities on or in the body. There are two different techniques used for palpation: light and deep palpation. 

Light palpation is gentle and gives information about skin texture and moisture, fluids, muscle guarding, and some superficial tenderness the patient may be experiencing. 

Deep palpation explores the internal structures of the body to a depth of four to five centimeters. 

Percussion

Nurses will palpate different body parts for sound vibrations. The most common is palpating the abdomen. Palpation can confirm the presence of air, fluid, and/or solids. It also is utilized to determine organ size, shape, and position. 

Auscultation

The final method used during a physical assessment is auscultation, or listening with a stethoscope to the different body systems of your patient. You will want to listen for lung sounds, heart sounds, and bowel sounds. APRNs can also be expected to listen to the neck for bruits. 

Step 1: Establish Trust

When beginning an assessment, Zucchero says, “Establishing a personal relationship of trust and respect between the patient and the nurse is vital.” She adds that it is important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable. You’ll want to introduce yourself to the patient and explain the assessment process

Step 2: Confirm the patient’s ID

Step 3: Note The patient’s Appearance and Status

“During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”

Step 4: Assess the ABCs

Prior to starting a detailed assessment, you’ll want to assess the ABCs  – airway, breathing, and circulation.

Usually, the assessment begins with the least invasive to most invasive, allowing time for the patient to become more comfortable with the examiner. It also increases the likelihood that the examiner will not forget a system during the exam.  

Step 5: Look for Abnormalities

Differentiating normal from abnormal is an important skill, Zucchero explains. 

Some examples of major abnormal findings are changes in normal respiratory rate that indicates respiratory distress, or a change in skin color such as pallor that may indicate anemia or jaundice that typically indicates liver problems.

Generally, the human body is bilaterally symmetrical. When you are examining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has a limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue.

Assessment Area

Assessment Tasks

General Status

  • Vital signs 
  • Heart rate
  • Blood pressure
  • Temperature
  • Pulse oximetry
  • Respiratory rate
  • Pain
  • Height/Weight/BMI

Assess pain using the appropriate pain scale for the patient

  • Numerical Scale
  • Wong-Baker Faces Pain Scale
  • FLACC Pain Scale
  • CRIES Pain Scale
  • COMFORT Pain Scale
  • McGill Pain Questionnaire
  • Color Analog Pain Scale

Head, Ears, Eyes, Nose, Throat (HEENT)

  • Inspect head tilt
  • Inspect skull and scalp
  • Inspect facial features
  • Palpate head and scalp
  • Auscultate temporal arteries if appropriate
  • Inspect  the color of lips and moistness
  • Inspect teeth and gums
  • Inspect  buccal mucosa and palate
  • Inspect  Tongue
  • Inspect  at uvula
  • Inspect  tonsils
  • Palpate nose and assess symmetry
  • Inspect septum and inside nostrils
  • Inspect  patency of nares
  • Inspect  patient’s sense of smell
  • Palpate sinuses
  • Perform whisper test
  • Perform tuning Fork test (Weber’s test, Rinne test)
  • Inspect  ear discharge and tympanic membrane
  • Inspect  conjunctiva and sclera
  • Inspect  eye symmetry
  • PERRLA
  • Check vision with Snellen Chart including distant visual acuity and near visual acuity.
  • Check six cardinal positions of the gaze
  • Inspect the external auditory canal
  • Inspect the tympanic membrane
  • Check for size, shape, symmetry, lesions, trauma
  • Check for thickening, hardness, and tenderness
  • Observe for masses, webbing, and skinfolds

Neck

  • Palpate lymph nodes
    • Parotid and retropharyngeal (tonsillar)
    • Submandibular
    • Submental
    • Sublingual (facial)
    • Superficial anterior Cervical
    • Superficial posterior cervical
    • Preauricular and postauricular 
    • Sternocleidomastoid
    • Occipital
    • Supraclavicular
  • Inspect and palpate trachea and neck
  • Inspect for Jugular Venous Distention
  • Inspect neck range of motion
  • Inspect shoulder shrug with resistance
  • Check for symmetry, tenderness, shape
  • Check thyroid for size, shape, configuration, tenderness, nodules

Respiratory 

  • Inspect the chest
  • Perform direct and indirect percussion on the chest
  • Auscultate lung sounds posteriorly and anteriorly
  • Inspect respiratory expansion level
  • Ask about coughing
  • Palpate thorax
  • Inspect nasal flaring and pursed lip breathing
  • Inspect configuration
  • Palpate for tenderness and sensation
  • Palpate for crepitus and fremitus
  • Percuss for diaphragmatic excursion
  • Percuss for tone

 

  • Inspect chest for size, shape, symmetry, color, superficial venous patterns, and prominence of ribs
  • Evaluate respirations for rate and rhythm
  • Auscultate for intensity, pitch, duration, and quality of breath sounds

Cardiac

  • Palpate the carotid and temporal pulses bilaterally
  • Auscultate the five areas of the heart 
  • Inspect the precordium 
  • Palpate apical pulse
  • Assess for murmurs
  • Listen for heart rate, rhythm, S1 and S2

Abdomen

  • Inspect abdomen
  • Auscultate 4 quadrants of the abdomen for bowel sounds
  • Palpate 4 quadrants of the abdomen for pain/tenderness
  • Percuss the 4 quadrants of the abdomen
  • Ask about problems with bowel or bladder
  • Inspect umbilicus
  • Inspect for aortic pulsations and peristaltic waves
  • Palpate the umbilicus and surrounding area for swellings, bulges, or masses
  • Inspect skin characteristics, venous patterns, symmetry, surface motion
  • Inspect masses, hernia, separation of the muscles
  • Listen for bruits
  • Check for tone, liver borders

Pulses

  • Palpate pulses in arms/legs/feet including,
    • Brachial (in infants)
    • Radial
    • Femoral
    • Posterior tibial
    • Dorsalis pedis

  • Ensure pulse are palpable and present 

Extremities

  • Assess range of motion and strength in arms/legs/ankles
  • Assess sharp and dull sensation on arms/legs
  • Perform capillary refill on fingernails/toenails
  • Palpate each joint in the hand and write
  • Test for carpal tunnel syndrome by performing Phalen’s test
  • Inspect  for muscle tone, warmth, tenderness, swelling, and crepitus
  • Inspect  for alignment, size, deformities, contour and symmetry

Skin

  • Inspect skin turgor
  • Inspect  for lesions, abrasions, rashes
  • Inspect  for tenderness, lumps, lesions
  • Inspect  if the patient is pale, clammy, dry, cold, hot, flushed
  • Inspect  for moisture, temperature, texture, turgor, elasticity
  • Inspect  for color, distribution, density
  • Identify pigmentation, length, redness, swelling, pain, growths

Neurological

  • Gait: posture, rhythm, sequence of stride and arm movements
  • Inspect for superficial touch and superficial pain response

Genitalia (this will vary on patient)

  • Palpate inguinal lymph nodes
  • Inspect labia majora, labia minora, clitoris, urethral meatus, and vaginal opening
  • Inspect the base of the penis and pubic hair
  • Inspect the skin of the shaft
  • Palpate the shaft
  • Inspect the foreskin and glans
  • Inspect the size, shape, and position of scrotum
  • Palpate the scrotum
  • Inspect for inguinal or femoral hernia 
 

Ferere adds that new nurses should trust the foundational knowledge obtained in nursing school and seek strong, supporting nursing mentors as resources in health care delivery settings. 

“Confidence in assessment continues to grow with every completed assessment. Nurses should not be afraid to ask for help when something does not seem right and rely on your instincts and training,” she says.

*This website is provided for educational and informational purposes only and does not constitute providing medical advice or professional services. The information provided should not be used for diagnosing or treating a health problem or disease.

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