Basic Head -to-Toe Assessment by Straight A Nursing
CATEGORY
STEPS
NOTES
INTRODUCTION
Greeting
Greet patient, introduce yourself, perform hand hygiene
Safety
Raise bed to a comfortable height for you; check patient’s arm band or verify name by
asking; ensure patient not in any acute distress.
Pain
Location, intensity, quality, radiation, duration, any relieving/exacerbating factors
LOC
How much stimulus does it take to rouse the patient or are they awake and alert? LOC
ranges from awake to somnolent, lethargic, stuporous, then comatose.
Orientation
Name, date, location, situation.
Skin
Assess for color, moisture, temperature. Normal is warm, dry, no discoloration.” Some
abnormal findings are pale, dusky, jaundiced, clammy, diaphoretic, cool, hot.
Facial droop
Assess for facial droop; have the patient smile
HEAD
Periorbital edema There are many causes for this including nephrotic syndrome and thyroid disorders.
Pupils
PERRLA: Pupils equal, round, reactive to light AND accommodation.
Eyes
Assess the sclera for discoloration, look for drainage, swelling, inflammation.
Neck
Cough
Look for retractions of neck muscles (indicated accessory muscle use); assess for
distended neck veins which can be caused by right heart failure and pulmonary
hypertension.
Assess for sputum; if present, assess color, consistency and amount.
NG tube
Check placement and patency; assess for skin breakdown at nares
Nasal cannula
Check for appropriate placement and FiO2; assess for skin breakdown at ears,
cheekbones and nares
Hand grip
Assess for equal grips by having patient squeeze your hands simultaneously
Radial pulses
Should be strong and regular
Nail beds
Assess for capillary refill; should be less than 3 seconds
IV site
Assess patency and dressing; assess for phlebitis (red, warm, tender) and infiltration
(edema, cool, maybe fluid leaking, maybe pallor).
PICC site
Assess dressing; assess for edema, redness and warmth (signs of DVT).
Skin turgor
Should quickly return to original state (may be decreased in elderly).
AV fistula
Assess for bruit (audible) and thrill (palpable)
CARDIAC
Heart sounds
Listen at apex for S1 and S2; S3, S4 and murmurs are abnormal findings. Apex is located
left side, MCL, 4th-5th ICS.
Two nurses one checks apical while other checks radial; count for one full minute
RESPIRATORY
Apical/Radial
pulse
RRPD
Lung sounds
Listen in three places: anterior, lateral and posterior
IS
Have patient use the incentive spirometer if available; assess for level obtained
WOB
Assess for work of breathing and shortness of breath. If patient can’t speak more than a
few words at a time, this is indicative of shortness of breath. Work of breathing is seen as
accessory muscle use, labored breathing.
Crepitus
Assess for crepitus if pt is at risk (chest tube, central line, trauma)
Appearance
Assess abdominal appearance (flat, rounded, distended, etc.)
Listen
Listen to bowel sounds. More frequently than q 5 seconds is hyperactive; less frequent
than q 15 seconds is hypoactive; no sounds in 2 minutes is absent (must listen in each
quadrant). Don’t forget to turn off NGT suction prior if using.
Feel
Palpate abdomen by pressing about 1cm; normal is soft and nontender.
Query
Ask about passing gas, last BM, appetite, nausea.
Catheter
Assess Foley catheter if present; ensure patency.
Urine
Assess urine color, clarity and for presence of sediment, clots or mucus.
Voiding
If voiding, ask about burning, frequency and amount
Pulses
Assess pedal pulses at posterior tibial and dorsals pedis
Edema
Start at the feet and assess upwards until edema ends; pitting edema vs non-pitting
edema.
Color
Look at color of feet; pale, mottled or dusky indicates per perfusion.
ARMS/HANDS
ABDOMEN
RENAL
LEGS
Respiratory rate, rhythm, depth, presences of air movement
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Basic Head -to-Toe Assessment by Straight A Nursing
CATEGORY
BACK
CLOSURE
STEPS
NOTES
Temperature
Assess temperature of feet. Cold extremities are a sign of poor perfusion and could
indicate ischemia.
Nail beds
Sensation
Assess for capillary refill at the nail beds (be careful with diabetic patients who have
neuropathy).
Assess for sensation; ask patient about numbness and tingling
Wounds
If patient has PVD or is diabetic, inspect feet carefully for wounds.
Homan’s Sign
Assesses for presence of DVT; not commonly done
Ankle strength
Have patient press feet against your hands in dorsiflexion and plantar flexion.
Edema
Assess for dependent edema, especially at sacrum.
Skin breakdown
Assess for redness at bony prominences or other signs of skin breakdown.
Position
Reposition patient if needed, lower bed, ensure it is locked and raise side rails (if using)
Safety
Place call light and overbed table within reach
Equipment
Check that O2 and suction are functioning.
Say goodbye
Ask patient if there’s anything else they need; let them know when you will return; perform
hand hygiene.
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