HEAD TO TOE ASSESSMENT
Introduce yourself and take vital signs
• BP, pulse rate, RR, (O2 sat if available at time of exam)
Head/Neck/Neuro
Observe
• General ability to breathe easily, level of alertness, ability to answer questions and interact
appropriately
Assess/Examine:
• Examine pupils for shape, size, symmetry, reaction to light
• Observe skin color
• JVD or other pulsations in neck
Anterior Chest/Abdomen
Observe/Assess
• Respiratory effort, use of accessory muscles
• Observe for rhythm, depth and symmetry of chest movement.
• Observe for cough, note severity and describe secretions if any.
• Note size, symmetry, contour of abdomen
Auscultate: (anterior)
• Heart sounds
o Anterior breath sounds
• Bowel sounds x4 quadrants
Palpate: (light palpation)
• Abdomen x4 quadrants
Posterior Chest/Abdomen:
Observe/Assess:
• Respiratory effort and equal expansion
Auscultate:
• Posterior breath sounds
Extremities – Arms
Observe/Assess
• Temperature and moisture (briefly!)
• Nails for color, clubbing
Palpate
• Cap refill
• Radial pulses simultaneously
• Strength – request pt to squeeze fingers simultaneously
• Assess ROM – active against resistance preferable
• Inspect symmetry and shape of muscles and joints
Extremities – Legs & Feet
Observe/Assess
• Temperature and moisture (briefly!)
• Nails for color, clubbing
• Assess ROM –
• Inspect symmetry and shape of muscles and joints
Palpate
• Cap refill
• DP, PT (feel bilateral feet simultaneously)
• Strength – request pt to lift feet up toward head against resistance, push down (gas pedal) against
resistance
• Edema across top of foot, ankles, and up shin (further if needed)
Head-to-Toe Assessment Guidelines