Head to Toe Assessment

[traumaRUs]

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 blood pressure. 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 is prolonged. 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 brachial pulses. Check the posterior tibia and dorsalis pedis pulses on both sides.

Heart sounds

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 in children, young adults, pregnant women - otherwise may be indicative of disease S4: extra heart sounds: end of diastolic, vibrations; usually abnormal to hear - may be indicative of disease

Murmurs

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 and functioning.

Musculoskeletal

Observe for gait disturbances, asymmetry, ability to ambulate, with or without assistance of another person, cane, wheelchair.

Reference:

Wright University

[nursemike, ASN, RN]

One hectic night, early in my career, I told my charge nurse that the only way I could get my assessments done would be to assess another system each time I put a patient back in bed, then stitch them all together when I charted. He gave me a slug on the shoulder and said, "now you're thinking like a nurse!" In the real world, you do have to improvise, at times, but it's important to have a solid foundation in the basics.

[Snowdin]

Thank you very much for sharing the methods of "Head to Toe - Rules of 3". I think that it will help a lot!

[HermioneG, BSN, RN]

nursemike said:

I've been practicing for 12 years. I still find your Rules of 3 a useful tool. Being succinct has never been my strong suit.

This makes me so happy, thank you!!!

[HermioneG, BSN, RN]

Snowdin said:

Thank you very much for sharing the methods of "Head to Toe - Rules of 3". I think that it will help a lot!

Thanks!! ? the positive feedback I got here inspired me and i ended up submitting it as an article so hopefully it can help more people! Its not perfect, but it has really helped me in my own personal practice.

[InfirmiereMaybe, BSN, RN]

HermioneG said:

That makes me really happy ? I really do hope that it can end up helping more people than I'll ever know!

I have a head to toe practicum next week. Thanks for sharing.

[al3x117, RN, EMT-B]

As dumb as this sounds just go from head to toe. What we had to do is video ourselves over and over and over again in skills lab. We rewatched every single video and were critical to each other over things that we missed to check on our patients. I will tell you though I can do a full head to toe no problem right now. I would advise you to not look at the check sheets that is the real trick. Do it from making your own sheet and break each body system with the assessment piece. Such as head = pupils, JVD, battle signs (bruising behind the ears), tongue movements, lympth nodes, tracheal deviation, looking inside the ears at the tympanic membrane for any s/s drainage and inflammation, etc. Then move onto chest = lung sounds, palpation, percussion, chest expansion, diaphragmatic excursion, etc. And then do that for every body system. I would write this stuff down on a huge white board if you have it and then do the full assessment over and over and over again. You will get better at this don't worry but you have to practice.