Head-to-Toe Assessment Equipment Checklist
Basic equipment includes:
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Gloves
Thermometer
Blood pressure cuff
Watch
Scale
Height wall ruler
Tape measure,
Penlight
Stethoscope
Additional equipment for more comprehensive examinations would include,
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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)
How to Conduct a Head-to-Toe Assessment
Step 1: Establish Trust
When beginning an assessment, “establishing a personal relationship of trust and respect between
the patient and the nurse is vital.” 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. 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 ABC's - 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.
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.
The Order of a Head-to-Toe Assessment
Assessment Area: General Status
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Vital signs
Heart rate
Blood pressure
Temperature
Pulse oximetry
Respiratory rate
Pain
Assessment Tasks:
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Assess pain using the appropriate pain scale for the patient
Assessment Area: Head, Ears, Eyes, Nose, Throat (HEENT)
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Observe head tilt
Inspect skull and scalp
Inspect facial features
Palpate head and scalp
Auscultate temporal arteries if appropriate
Observe the color of lips and moistness
Inspect teeth and gums
Assess buccal mucosa and palate
Examine Tongue
Examine at uvula
Examine tonsils
Palpate nose and assess symmetry
Check Septum and inside nostrils
Verify patency of nares
Check patient’s sense of smell
Palpate sinuses
Assess patient hearing with whisper test
Tuning Fork test (Weber’s test, Rinne test)
Look inside ear
Assess ear discharge and tympanic membrane
Check conjunctive and sclera
Assess eye symmetry
PERRLA
Check vision with Snellen Chart
Check six cardinal positions of the gaze
Assessment Tasks:
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Check for size, shape, symmetry, lesions, trauma
Check for thickening, hardness, and tenderness
Observe for masses, webbing, and skinfolds
Assessment Area: Neck
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Palpate lymph nodes:
o Parotid and retropharyngeal (tonsillar)
o Submandibular
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o Submental
o Sublingual (facial)
o Superficial anterior Cervical
o Superficial posterior cervical
o Preauricular and postauricular
o Sternocleidomastoid
o Occipital
o Supraclavicular
Observe and palpate trachea and neck
Check for Jugular Venous Distention
Check neck range of motion
Check shoulder shrug with resistance
Assessment Tasks:
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Check for symmetry, tenderness, shape
Check thyroid for size, shape, configuration, tenderness, nodules
Assessment Area: Respiratory
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Inspect the chest
Perform direct and indirect percussion on the chest
Listen to lung sounds front and back
Assess respiratory expansion level
Ask about coughing
Palpate thorax
Assessment Tasks:
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Observe chest for size, shape, symmetry, color, superficial venous patterns, and prominence of ribs
Evaluate respirations for rate and rhythm
Palpate for thoracic expansion, tactile fremitus
Listen for intensity, pitch, duration, and quality of breath sounds
Assessment Area: Cardiac
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Palpate the carotid and temporal pulses bilaterally
Auscultate the five areas of the heart
Inspect the precordium
Assessment Tasks:
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Assess for murmurs
Listen for heart rate, rhythm, S1 and S2
Assessment Area: Abdomen
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Inspect abdomen
Listen to 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
Assessment Tasks:
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Check for skin characteristics, venous patterns, symmetry, surface motion
Check for masses, hernia, separation of the muscles
Listen for bruits
Check for tone, liver borders
Assessment Area: Pulses
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Palpate pulses in arms/legs/feet including:
o Brachial (in infants)
o Radial
o Femoral
o Posterior tibial
o Dorsalis pedi
Assessment Tasks:
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Ensure pulse are palpable and present
Assessment Area: Extremities
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Assess range of motion and strength in arms/legs/ankles
Assess sharp and dull sensation on arms/legs
Check capillary refill on fingernails/toenails
Palpate each joint in the hand and write
Assessment Tasks:
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Check for muscle tone, warmth, tenderness, swelling, and crepitus
Check for alignment, size, deformities, contour and symmetry
Assessment Area: Skin
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Check skin turgor
Check for lesions, abrasions, rashes
Check for tenderness, lumps, lesions
Check if the patient is pale, clammy, dry, cold, hot, flushed
Assessment Tasks:
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Check for moisture, temperature, texture, turgor, elasticity
Check for color, distribution, density
Identify pigmentation, length, redness, swelling, pain, growths
Assessment Area: Neurological
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Test cranial nerves I through XII
Evaluate balance using the Romberg test
Evaluate coordination and fine motor skills
Test primary sensory responses
Oriented x3
Assess gait
Assess superficial and deep tendon reflexes
Check the Glasgow Coma Scale score
Assessment Tasks:
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Gait: posture, rhythm, sequence of stride and arm movements
Check for superficial touch and superficial pain response
FAQs:
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What 4 techniques are used in a head-to-toe assessment?
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How do you do a head-to-toe assessment?
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To perform a thorough head-to-toe assessment, it is recommended that you start with
an overall inspection of the patient and then move to the head, ears, eyes, nose and
throat. Then, move your way down the body systematically. You will need to include the
four techniques of inspection, palpation, percussion, and auscultation throughout the
assessment.
What is the purpose of a head-to-toe assessment?
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The four techniques that are used for physical assessment are inspection, palpation,
percussion, and auscultation.
The purpose of a head-to-toe assessment is to get a baseline understanding of your
patient. This assessment can be used in case there is an emergency or a change in their
physical or emotional behavior. It also can be used to help diagnose a disease or illness.
What should the nurse begin by assessing when performing a head-to-toe assessment?
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This will depend on the patient. Typically, the first thing a nurse should do is look or
inspect. Use your eyes to look at your patient’s skin, breathing, and outward appearance
before moving on to more invasive aspects of the assessment. However, it is best to
start at the head for a systematic top-to-bottom approach.