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

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.

Free Cheat Sheets For Everyone!

We also want to remind you to subscribe to the Ace Nursing School Blog Newsletter, where you’ll receive free cheat sheets every single week! No personal information required, no spam, just cheat sheets!

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
Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s