Head to Toe Assessment
As a student you are learning many new skills and have many expectations from your lessons. However, one of the basic but most important is the head-to-toe assessment.
The head-to-toe assessment is one of the basic skills all nurses need to develop. No matter what specialty you go into, assessment is one of the first objectives of any patient interaction. Here is an excellent video that shows a step by step head-to-toe assessment. It is very important to understand exactly what is required and that you develop a systematic way of doing the assessment and that you do it the same way each time.
Every school/institution might have a different way of doing this. However, a general head to toe assessment should include all of the following and may include a more detailed exam. Rectal/pelvic exams are often deferred to the provider. Pediatric patient assessment includes a more detailed developmental exam and is not addressed in this video.
An across the room assessment. As you enter the room, look at the patient:
Do they turn their head towards you, acknowledge you verbally?
Skin color? Are their lips blue-tinged, are they conversing in full sentences? Sitting upright or lying supine in bed?
If they were sleeping, how many pillows are in use? Do they have the head of the bed raised?
What is their work of breathing? Do they breathe rapidly? Gasping? Snoring respirations? Even?
Obtain the patient's vital signs: generally described as the measurement of temperature, pulse, respirations and bloodpressure. This gives an immediate picture of a person’s current state of health.
Examination of skin - color and uniformity of color, moisture, hair pattern, rashes, lesions, pallor, edema, temperature, turgor, lesions, edema, texture
Head - look for scars, lumps, rashes, hair loss, or other lesions. Look for facial asymmetry, involuntary movements, or edema. Identify any areas of tenderness or deformity.
Neck - inspect the neck for asymmetry, scars, or other lesions. Palpate the neck to detect areas of tenderness, deformity, or masses.
Chest/Lungs - Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase isprolonged. Listen for obvious abnormal sounds with breathing such as wheezes. Observe for retractions and use of accessory muscles (sternomastoids, abdominals). Observe the chest for asymmetry, deformity, and confirm that the trachea is near the midline
Cardiovascular and Peripheral vasculature - Check the radial pulses on both sides. If the radial pulse is absent or weak, check the brachialpulses. Check the posterior tibia and dorsalis pedis pulses on both sides.
S1: normal: closure AV, start systole, heard all over, loudest apex
S2: normal: closure of semilunar valves, end systole, all over but loudest base, “dub”
S3: extra heart sounds: vibrations that come from filling ventricles, start diastolic usually; audible inchildren, young adults, pregnant women – otherwise may be indicative of diseaseS4: extra heart sounds: end of diastolic, vibrations; usually abnormal to hear – may be indicative ofdisease
1. Grade i-ii functional systolic murmurs are common in young children and resolve with age2. Auscultate for blowing, swishing sound.
3. Some are ‘innocent” murmurs, but most are indicative of disease.
4. Murmurs are graded. A grade “2” murmur would be rated ii/vi.
Abdomen - Look for scars, striae, hernias, vascular changes, lesions, or rashes. Look for movement associated with peristalsis or pulsations. Note the abdominal contour. Is it flat, scaphoid, or protuberant? Place the diaphragm of your stethoscope lightly on the abdomen. Listen for bowel sounds. Are they normal, increased, decreased, orabsent? Borborygmus = “growling”. Listen for bruits over the renal arteries, iliac arteries, and aorta.
Neuro - Assess level of consciousness; facial expression and body language; speech; cognition andfunctioning.
Musculoskeletal - observe for gait disturbances, asymmetry, ability to ambulate, with or without assistance of another person, cane, wheelchair.
Wright UniversityLast edit by Joe V on Dec 20, '16
About traumaRUs, MSN, APRN Admin
traumaRUs has '20+' year(s) of experience and specializes in 'Heart Failure, Nephrology, ER, ICU'. From 'Midwest'; Joined Apr '00; Posts: 51,559; Likes: 24,315.Dec 5, '16I didn't read the article completely and didn't watch the video, but I do have something to say...
Thorough, but easy to comprehend. And let me just say, I commend you for finding a Head to Toe assessment from YouTube! It is NOT easy to weed through all those inaccurate, unprofessional or just over the top videos. I will be returning to school in Jan. for my RN-ASN! Woot woot! Then on to my BSN via online. Really want to obtain my MSN but I will take it one step at a time. Thanks for your article!Dec 5, '16[QUOTE=BabyFood26;9269322]I didn't read the article completely and didn't watch the video, but I do have something to say...
LOL Thanks for watching the video. (This one and the other one)Dec 6, '16Thank you for posting this. I will get to do my first assessment on my next clinical day. It's been about 2 wees since we covered this in class so the demo got it back to being fresh in my mind.
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