Head-to-Toe Assessment

  1. Hello! I am looking for some help. The college where I teach is considering going to a head-to-toe assessment for our 1st year BScN students and we don't know where to begin....we are searching through texts but we are looking for something that is 10 - 15 minutes to complete.
    Is there anyone out there with a lead or willing to pass on their checklist?
    I could really use the help!
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    About Nurse Bethie

    Joined: May '03; Posts: 29; Likes: 4
    Nurse Technologist


  3. by   toronto rn
    Do you mean 10-15 minutes to do a complete assessment?
    How in-depth would you like it to be?
  4. by   jenac
    Do you want the list of what to look at?
    I still have my Head 2 Toe card from school and am willing to share it if this is what your looking for.
  5. by   bklynborn
    I would like to see that head to toe card...............................
  6. by   Nurse Bethie
    Thanks for all your responses...I am looking for a quick head to toe with ability to assess the general health status then do a focus examination on the primary needs (like what we do at the beginning of shifts). My students are first year degree students and need a lot of direction as the what to llok at....we are having trouble writing it down for them...not so easy pulling it out of your head and making it make sense on paper....this Head to toe card sounds wonderful...I would love to see it..
    Thanks again
  7. by   jenac
    I'm sorry guys, I got caught up with my kids this afternoon and didn't get to check in earlier! I'm getting ready to run back to work for a split shift, but I will post the copy of my Head 2 Toe card in the morning as soon as I get home, bright and early. Hope this is ok-and sorry again. Have a good night all!
  8. by   jenac
    Ok- here is my head 2 toe card. Pardon any spelling errors, it's been a long night! It was made specific for med-surg, but can be adapted to any area (I used the same one, specified to OB). Imagine a stick figure (I actually have one in the corner...), from head 2 toe:
    In parenthases-I used prompters for the specifics.

    LOC (alert/lethargic/non-responsive)
    Orientation (to person,place and time)
    Neuro check, if applicable
    Skin-color (pale/ pink/ruddy)
    Temp (cool/cold/warm/hot)
    Texture (dry/diaphoretic)
    *Any O2, NG tubes would go here
    rhythm (regular/irregular or normal/abnormal)
    effort (easy/non-labored)
    deepth (deep/shallow/blowing)
    *Chest tubes would go here
    Upper extremities- If IV present, note the solution, the rate and the site. Note the site for warmth, redness,edema etc.
    Abdomen-look (round/flat)
    listen (BOSO present x 4 quads?Rhythm of BOSO-normal/hyper/hypoactive and the intensity-high/low-pitched)
    feel (soft/firm/hard)
    *Any PEG,PEJ,etc. tubes would go here.
    Bowel and Bladder- voiding (color, clarity,amount)
    Postop flatus?
    Foley? (patent, note drainage system)
    Ostomy? (note stoma)
    *This would include any suprapubic caths,drains,etc.
    Lower Extremities-
    Homan's sign (negative/positive)
    Pedal pulses (+1=weak/faint, +2 palpitable, +3 bonding)
    Capillary refill (brisk/sluggish-how long if >3 seconds)
    **We were taught to put any dressings or wounds in the order they came. For example, a forarm dressing would go with the upper extremities. A cast would include a circ check with the corresponding area. Edema include pitting (and the deepth) or nonpitting at the correspodning area.

    I hope this helps. I don't know if it was specific to my school or not-but I still use it today to find a problem area. It's great for focusing in on a specific problem. For us- we further went on, later in the day to assess activity, I & O, etc. It takes practice to be able to do it in 15 minutes-but it comes so automatic after awhile that you start it as soon as you walk in a room.

    On that note- I'm off to bed. Have a great day everyone.
  9. by   jenac
    I had this all centered so nicely, so that it would be easier to read-but when I posted it, it got all funky! Sorry about that.
  10. by   Nurse Bethie
    Thank you so much! This is goin to be a great tool for my students....helping them organize their thoughts until they can do this at the end of a 12 hr shift! You are a truly wonderful asset to me and my students!!!!!
  11. by   jenac
    You are very welcome. I'm glad I could help.
  12. by   cynt
    Quote from jenac
    Do you want the list of what to look at?
    I still have my Head 2 Toe card from school and am willing to share it if this is what your looking for.
  13. by   cynt
    Quote from jenac
    Do you want the list of what to look at?
    I still have my Head 2 Toe card from school and am willing to share it if this is what your looking for.
  14. by   ktstone
    Hello All! I am a nursing student but do have a Masters in Network Security so I found some links for you and or your students for a full assessment (videos). I don't know how long they will be or the quality. If you need more please send me a private message (PM). I would be happy to find anything you need if I have the time. I will need to know which text you use and maybe more information so I can find things directly related to your text that will flow directly with the material that you have covered.


    Last edit by VickyRN on Aug 25, '05