Everything You’ll EVER Need to Know About Head-to-Toe Assessments!

Ace Nursing School health assessment

The BEST Online Head-to-Assessment Guide for Nurses!

What is a head-to-toe assessment?

This is a complete guide that will take you through each step of a head-to-toe assessment. It is very easy simple, easy to follow, and effective. It will answer virtually any questions you could ever have about head-to-toe assessments!

This is part 3 of a 5 part series covering health assessment. Part 1 is a step-by-step guide of a health history. Part 2 is an overview of a physical assessment. Part 3 is everything you need to know about vital signs. Part 5 covers a mental assessment.

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Nursing Necessities Cheat SheetComplete Head-to-Toe Assessment (Nursing)

 

  • Preparation
    • Wash your hands on entering the room
    • Introduce yourself to the patient
    • Explain what a head-to-toe assessment is and why you are completing it
      • It is an assessment of each of the body systems to get an understanding of the patient’s current general health status

 

  • General Survey
    • As you introduce yourself to the patient and obtain a health history note the following:
      • Asleep, awake, easily aroused?
      • Eye contact (signs of abuse or cultural differences)
      • Appearance (dressed appropriately for weather?)
      • Hygiene
      • Respiratory effort
      • Skin color (flushed, pale, etc.)
      • Speech (education level; impairments?)
      • Pain
      • Signs of distress
      • Alert and oriented (A&O) – to person, place, and time
    • Start with this to get a broad idea of their mental status
  • Vital Signs
    • Body temperature
      • 6°F
    • Pulse (chart)
      • Rate (60-100bpm)
      • Rhythm (steady)
      • Intensity
      • Compare pulses bilaterally and compare
PULSES: Peripheral pulses should be compared for rate, rhythm, and quality.
0 Absent
+1 Weak and thready
+2 Normal
+3 Full
+4 Bounding

 

 

 

 

 

  • Respirations
    • Number of breaths taken per minute (12-20)
      • Count number of breaths taken in 30 seconds and multiply by 2
      • One inhalation and one exhalation = one breath
      • Do not tell patient you are measuring their breathing rate – it affects the results
    • Blood pressure
      • 90-120mmHg/60-80mmHg
    • Oxygen Saturation
      • 95%-100%

 

  • Nutrition Status
    • Height (cm)
    • Weight (kg)
    • Lifestyle (active/moderate/sedentary)
    • Diet
    • Risk factors for altered nutrition status

 

  • Neurological
    • Stimulus response
    • Chart level of arousal by:
      • Stimuli needed to elicit response (auditory, physical, painful)
      • Type of response elicited (no response, wincing, eye-opening, etc.)
    • Glasgow Coma Scale
      • Best response: 15
      • Comatose client: 8 or below
        • Indicates severe head injury
      • Totally unresponsive: 3
  • Pupils – PERRLA
    • P – Pupils
    • E – Equal (size)
    • R – Round (shape)
    • R – Reactive to
    • L – Light and
    • A – Accommodation
  • Deep tendon reflexes
    • 0+ = reflex absent
    • 1+ = sluggish/diminished
    • 2+ = normal
    • 3+ = slightly hyperactive
    • 4+ = hyperactive with clonus
  • Motor function
    • Squeeze with both hands at same time
    • Push with both feet at same time
    • Note any one-sided weakness or drooping
  • Sensory function
    • Touch
    • Pain
    • Temperature
    • Pressure
    • Vibration
    • Vision
    • Hearing
    • Smell
    • Taste
  • Mental status exam
    • Appearance
    • Behavior
    • Insight
    • Intellectual functioning
    • Judgement
    • Memory
    • Mood and affect
    • Orientation
    • Perceptual processes
    • Sensorium
    • Thought content
    • Thought processes
  • Short Portable Mental Status Questionnaire (SPMSQ)
    • Series of 10 common knowledge question related to orientation
    • 0-2 errors = intact intellectual functioning
    • 3-4 errors = mild intellectual impairment
    • 5-7 errors = moderate intellectual impairment
    • 8-10 errors = severe intellectual impairment

 

  • Respiratory
    • Anteroposterior : transverse diameter = 1:2
      • 1:1 = barrel chest (COPD)

1:2           1:1 (barrel chest)

  • Breathing difficulty
  • Both sides rise evenly
  • Sputum
    • Color
    • Consistency
  • Cough
    • Productive
    • Nonproductive
  • Is patient receiving supplemental oxygen?
  • Breathing patterns
    • Abdominal respirations – breathing accomplished by abdominal muscles and diaphragm
    • Apnea – temporary cessation of breathing
    • Cheyne-Stokes – breathing becomes deeper and faster, then decreases to apnea, then repeats
    • Dyspnea – difficult or painful breathing
    • Hyperpnea – extremely deep breathing
    • Hyperventilation – extremely rapid, deep breathing
    • Hypoventilation – extremely slow breathing
    • Kussmaul’s – marked increase in depth and rate (appears hungry for air)
    • Orthopnea – body must be upright to breathe
    • Paradoxical – one lung deflates during inspiration
    • Periodic – pauses in breathing for 10 seconds followed by rapid shallow breaths
  • Breathing Sounds
    • Crackles – brief rattling sound caused by explosive opening of small airways, usually due to inflammation.
    • Rales – small clicking, bubbling, or rattling sounds in lungs heard on inhalation. May be described as moist, dry, fine, or coarse
    • Rhonchi – low-pitched, snoring, gurgling sound
    • Stridor – extremely high-pitched “wheeze” usually due to blockage of air flow in trachea
    • Wheeze – high-pitched sound produced by a narrowed or obstructed airway best heard on exhalation (asthma)

Order of auscultation

  • Cardiac
    • 5 P’s of circulation
      1. Pain – is it present?
      2. Pallor – is extremity losing color?
      3. Paralysis – is extremity losing mobility?
      4. Paresthesia – is there a tingling sensation?
      5. Pulse – is it palpable?

Common areas to palpate a pulse

  • Capillary refill (<3 seconds)
  • Jugular veins
  • Telemetry (heart rhythm)
EDEMA: Assess by placing thumb over dorsum of the foot or tibia for 5 seconds
0 No edema
1+ Barely discernible depression
2+ A deeper depression (< 5 mm) w/ normal foot & leg contours
3+ Deep depression (5-10 mm) w/ foot & leg swelling
4+ Deeper depression (> 1 cm) w/ severe foot and leg swelling
  • Edema (especially in legs) (chart)
  • Normal heart sounds
    • S1 (“lub”)
      • Closure of tricuspid and mitral valves. Dull and low-pitched.
    • S2 (“dub”)
      • Closure of aortic and pulmonic valves
    • Abnormal heart sounds
      • S1 split
        • S1 sounds like it is split in half
      • S2 split
        • S2 sounds like it is split in half
      • S3 (ventricular gallop)
        • Normal in healthy children
        • Abnormal in adults
        • Sounds like “Kentucky”
          • S1         S2      S3
          • “Ken”     “tuck”   “ee”
          • “Lub”     “dub”     “dub”
        • S4 (atrial gallop)
          • Sounds like “Tennessee”
            • S1         S2       S3
            • “Ten”     “ne”     “see”
            • “Dub”     “lub”     “dub”
          • Pericardial friction rub
            • Coarse, grating sound over heart
            • Have patient hold his breath. If sound continues, it is of cardiac origin (not pleural)
          • Mediastinal crunch
            • Sounds like popcorn crunching
            • Indicates air in mediastinum
          • Heat Murmurs (include chart)
            • Caused by increased flow through normal structures
            • Systolic murmur – occur between S1 and S2
            • Diastolic murmur – occur between S2 and S1
  • Grades of murmurs:
  • Order to auscultate
    • Mnemonic to remember each one: All People Enjoy The Mall – 2, 2, 3, 4, 5 (intercostal spaces)
    • A – Aortic – 2nd right intercostal space
    • P – Pulmonic – 2nd left intercostal space
    • E – Erb’s Point – 3rd left intercostal space
    • T – Tricuspid – 4th left intercostal space
Grade I Faint; heard with concentration
Grade II Faint murmur heard immediately
Grade III Moderately loud, not associated with thrill
Grade IV Loud and may be associated with a thrill
Grade V Very loud; associated with a thrill
Grade VI Very loud; heard w/stethoscope off chest, associate w/a thrill
  • M – Mitral – 5th left intercostal space

 

  • Integumentary
    • Color
      • Pink (normal)
        • In patients with dark skin, it is easier to assess the mucous membrane or conjunctiva
      • Pale
      • Flushed
      • Red
      • Brown
      • Yellow (jaundice)
      • Mottled
    • Texture
      • Dry
      • Moist
      • Diaphoretic
    • Injuries (find out cause)
      • Scars
      • Bruises
      • Lesions
      • Rash
    • Temperature
      • Warm
      • Hot
      • Cool
    • Turgor
      • Pinch skin – tented less than 3 seconds is normal
    • Decubitus ulcers (bony prominences)
      • Stage 1 = redness
      • Stage 2 = break in skin
      • Stage 3 = visible muscle
      • Stage 4 = visible bone
      • Unstageable = full thickness tissue loss
  • Hair
    • Even distribution?
    • Alopecia – hair loss/thinning
    • Hirsutism – abnormal excess

 

  • Head
    • Size
    • Shape
    • Symmetry
    • Cranial nerve function

 

  • Eyes
    • Symmetrical
    • Color of sclera and conjunctiva
    • Peripheral vision
    • Acuity
      • Snellen chart (20/20 is normal)

 

  • Ears
    • Pull pinna up and back to examine patient’s 3 years of age and greater
    • Pull pinna down and back to examine patient’s under 3 years of age

 

  • Nose/Sinuses
    • Alignment (septum)
    • Discharge
      • Color
      • Consistency

 

  • Mouth
    • Mucosa
    • Teeth
      • Chips, cavities, missing, dentures
    • Tongue
      • Color, hygiene
    • Tonsils
    • Ability to swallow

 

  • Nails
    • Color
    • Shape
      • Normal = angle of nail bed is less than 160 degrees
      • Clubbing = angle of nail bed is greater than 180 degrees
        • Due to prolonged decreased oxygenation
  • Breasts
    • Size
    • Shape
    • Symmetry
    • Masses or lumps
    • Gynecomastia – enlarged breasts in males
  • Abdomen
    • Order of abdominal assessment is different than other areas of body
      • Inspect
      • Auscultate
      • Percuss
      • Palpate
    • Symmetry
    • Contour
      • Flat
      • Rounded
      • Protuberant
      • Scaphoid
    • Palpate for rebound tenderness
  • Gastrointestinal
    • Inspect
      • Flat
      • Rotund
      • Distended
    • Auscultate
      • All 4 quadrants
        • Right upper quadrant
        • Left upper quadrant
        • Right lower quadrant
        • Left lower quadrant
      • Bowel sounds
        • Hypoactive = ❤ sounds per minute
        • Normoactive
        • Hyperactive = loud and frequent
        • Absent = no bowel sounds for at least 5 minutes of ausculating
      • Palpate
        • Pain
        • Rebound tenderness
        • Masses
      • Percuss
        • Air filled or fluid filled?
      • Nausea/vomiting?
      • Tubes present
        • Tube feedings
      • Stoma present
        • Stoma status
          • Pink (normal)
          • Red
          • Dusky
          • Dark
          • Retracted
          • Infected
        • Stool
          • Time of last bowel movement
          • Color
          • Character
          • Consistency
  • Musculoskeletal
    • Alignment of neck and spine
    • Range of motion of neck and spine
    • Joint movement
    • Muscle strength
    • Wheelchair/walker/cane?

 

  • Genitourinary
    • Urination
      • Amount (<30mL/hr is normal)
      • Color
        • Yellow
        • Amber
        • Orange
        • Pink
        • Red tinged
        • Bloody
      • Characteristics
        • Cloudy
Symptom Analysis: This assists the client in describing the problem.
P Provocate/Palliative: What caused it? What makes it better/worse?
Q Quality/Quantity: How does it feel, sound, look, how much?
R Region/Radiation: Where is it and does it spread?
S Severity Scale: Rate on appropriate pain scale. Does it interfere with ADLs?
T Timing: When did it start? Sudden/gradual? How often? How long does it last?
  • Sediment
  • Abnormal odor
  • Burning
  • Frequency
  • Urgency
  • Bladder distention
  • Flank pain
  • Continent/incontinent
  • Stents?
  • Catheter?

 

  • IV Assessment
    • Type of line
      • Peripheral
      • PICC
      • Central
    • Insertion site
      • Location
      • Redness
      • Pain
      • Warmth
      • Swelling
      • Drainage
      • Gauge
    • Fluids
      • Rate
      • Lock
        • Saline
        • Heparin
      • Pain
        • Scale of 0-10
        • Wong-Baker (faces) scale for children

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