How to Conduct a Nursing Head-to-Toe Assessment
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
What is a Head-to-Toe Assessment?
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.
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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.
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.
How Long Are Head-to-Toe Assessments?
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.”
How to Prepare for Head-to-Toe Assessments
“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.”
Head-to-Toe Assessment Equipment Checklist
Depending on the type of assessment conducted, the nurse may need specific equipment.
Basic equipment includes:
- Blood pressure cuff
- Height wall ruler
- Tape measure,
Additional equipment for more comprehensive examinations would include,
- 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)
Techniques Used During Physical Assessment
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.
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.
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.
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.
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.
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How to Conduct a Head-to-Toe Assessment
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.
The Order of a Head-to-Toe Assessment
Assess pain using the appropriate pain scale for the patient
Head, Ears, Eyes, Nose, Throat (HEENT)
Genitalia (this will vary on patient)
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.
What 4 techniques are used in a head-to-toe assessment?
- The four techniques that are used for physical assessment are inspection, palpation, percussion, and auscultation.
How do you do a head-to-toe assessment?
- 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?
- 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?
- 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.
*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.