the basics of the head to toe assessment

8/7/2019 The Basics of the Head to Toe Assessment

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The Basics of the Head to Toe Assessment:

This is the basics of a head-to-toe assessment which is a vital aspect

of nursing. It should be done each time you encounter a patient for thefirst time each shift (or visit, for home care, clinic or office nurses).

This assessment includes assessment of the physical, emotional and

mental aspects of all body systems as well as the environmental andsocial issues affecting the patient. The nurse needs to observe for all

of these factors and ask questions as needed. When you enter theroom, attempt to establish eye contact with the patient. This will show

you if they are alert or if this needs to be further investigated. Address

them by name and introduce yourself. When they answer you, this willshow you how clear their speech is and if they are oriented to self. Do

their eyes meet yours or do they wander? Are they blind or hearing-impaired? This can all be determined in a few seconds.

Difficulty: Average

Time Required: Approximately 10-20 minutes

Procedure:

1. Assemble your equipment. Wash your hands. Greet and identify thepatient. Explain what you are going to do. Provide for privacy.

Begin with the 5 Vital Signs: Temperature, Pulse, Blood Pressure,Respiration and Pain. Ask the patient how he/she feels and observethe environment. As you assess the body by systems, observe for

such tings as non-verbal cues, mobility and ROM.2. HEENT/Neuro :

o Head: shape and symmetry; condition

of hair and scalp

o Eyes: conjunctiva and sclera, pupils;

reactivity to light and ability to follow

your finger or a light

o Ears: hearing aids, pain? Speak in a

whisper: can he hear you andcomprehend? Turn away to make sure he isn't reading your

lips.

o Nose: drainage, congestion, difficulty breathing, sense of

smell

o Throat and Mouth: mucous membranes, any lesions, teeth or

dentures, odor, swallowing, trachea, lymph nodes, tongue


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3. Level of Consciousness and Orientation: Is he awake and alert? Ishe oriented to Person (knows his name), Place (he can tell you

where he is) and Time (knows the day and date). A fourth level of

orientation is Purpose (he knows why you are examining him; orknows the function of something such as your penlight orstethoscope).

4. Skin: As you examine all body systems you need to make note of

the status of the Integumentary System for any breaks in the skin,

scars, lesions, wounds, redness, or irritation. Assess the turgor,

color, temperature and moisture of the skin Have them roll over ontheir side, and check their back, buttocks, and perineal area if

appropriate for the situation. This will also help you tell how wellthey can move around in the bed.

5. Thoracic region: Assess lung and cardiac sounds from the front and

back. Assess them for character and quality as well as for thepresence or absence of appropriate sounds. Palpate the chest wall

and breasts for any tenderness or lumps. While you listen to theirbreath sounds, you can check the skin for lesions and assess the

condition of dressings.6. Abdomen: Listen to bowel sounds throughout the 4 quadrants.

Palpate for tenderness or lumps. Palpate the bladder. Ask aboutintake and output of bowels and bladder. Ask about appetite.

Assess genitalia for tenderness, lumps or lesions.7. Extremities: Assess for temperature, capillary fill and ROM. Palpate

for pulses. Note any edema, lesions, lumps or pain.Ask them ifthey feel pain when you touch them, check for the Homan's sign.General Questions: Ask the patient how he feels. Has anything

changed recently? Any pain, burning, SOB, chest pains, change in

bowel or bladder habits/function, change in sleep habits, cough,discharge from any orifice, depression, sadness, or change in

appetite?8. Wash your hands .

Document your findings.Report any significant changes or findings to the PCP (primary care

practitioner).9. Evaluate your assessment in terms ofThe Nursing Process
http://www.thenursingsite.com/Articles/the%20nursing%20process.htmhttp://www.thenursingsite.com/Articles/the%20nursing%20process.htm


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What You Need:

Stethoscope

Thermometer Sphygmomanometer

Penlight

Tape measure

Watch with second hand

Pen

Assessment forms or note paper

Make sure while you are doing your assessment to ask the patient if

they have any special needs during their stay. A lot of time nursesmiss things simply because they don't ask the patient if they need help

to the restroom, if they're hard of hearing, or if they have poor night

vision. Most patients will share with you if you ask. They'll tell youthey're incontinent at night or that they wear dentures or other things

of importance if you'll just take a few minutes and listen to them. Thisis as important as your physical assessment and will leave a lasting

positive impression on the people you care for during your shift.

the basics of the head to toe assessment

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