Head to Toe Assessment Simplified Steps
Upon Entering the Room (Pre-Procedure)
 Evaluate lower extremities skin for color, temp,
hair distribution, edema & breakdown
 Knock & enter
 Bend knees toward head, supporting at joints
 Hand hygiene
 Posterior tibial pulses for rate, rhythm &
 Introduce self & state reason for entering
amplitude
 Identify client (name & DOB)
 Dorsal pedis pulses for rate, rhythm &
 Assess for comfort
amplitude
 Adjust bed to comfortable working height.
 Wiggle feet/toes
Lower siderail
 Capillary refill on toes
 Push down & up on hand with feet
Environmental Sweep
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Evaluate tubes, drains, oxygen, & safety issues
Oxygen: verify delivery system, flow rate, & is
oxygen not air
IV: locate site, correct fluid/rate, type, dressing,
& insertion site (color & temp)
Foley Catheter: proper position on frame, not
kinked (color, clarity, & amount)
Things that Involve the Stethoscope
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Cardiac Assessment
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General Appearance
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Signs of distress or pain (cardiac, resp, pain,
anxiety, depression)?
“Are you in a comfortable position?”
Physical deformities? Symmetrical head to toe?
Appear stated age?
Appropriate mood & affect?
Language barriers? Difficulty with speech or
hearing?
How does hygiene appear? Any body odors?
Appropriate clothing?
Throughout assessment, evaluate skin of entire
body
Neurological Evaluation and Head
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Pupils with penlight, note drainage, redness, or
edema
Ears, note drainage, redness, or edema
Extraocular movement & pupil accommodation
Carotid pulses (one at a time)
Shrug shoulders with resistance
Gentle pressure on cheek while turning head to
side
Stick out tongue & smile
Peripheral vision
Extremities Evaluation
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Radial bilateral pulses for rate, rhythm &
amplitude
Capillary refill on fingers
Squeeze two fingers
Hand hygiene
Clean stethoscope
Sit upright & make sure comfortable
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Auscultate aortic, pulmonic (S2), Erbs point,
tricuspid, & mitral (apical, S1) with diaphragm &
bell on skin (not over clothing)
S1 & S2 & any adventitious sounds at each point
Auscultate apical pulse for 1 min & evaluate
heart rate
Lung Sounds
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Lung sounds 6 spots anterior & posterior chest
ladder technique; listen for adventitious sounds
(rhonchi, crackle, wheezing)
Evaluate skin on back
Abdominal Assessment
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Assist to lie flat
Remove clothing for inspection (contour,
pulsations, bruising)
Auscultate 4 quadrants
Auscultate abdominal bruit with bell
Auscultate carotid bruit each side with bell
Palpate abdomen
Reposition client so comfortable, call light in
reach, & bed low position