Hey there!
A few weeks ago I received an email from a student asking for help and encouragement for completing a head to toe assessment on a real.live.human. *AH!*
Oh my gosh, I remember my head to toe assessment checkoff day. I was flipping terrified! I had practiced so many hours, and I’m pretty certain my husband was getting a little tired of being my guinea pig.
The head to toe assessment exam is kind of like a right of passage in nursing school. It’s painful, but necessary. Because every shift for the rest of your life, you will constantly be assessing and reassessing…and reassessing..and reassessing. Oh, and reassessing.
You will eat, sleep and breathe the nursing assessment.
And there will come a day when your nursing assessment skills will be the deciding factor in whether your patient lives or dies. Over time, you will sharpen your assessment skills to anticipate a code before it happens, to get a gut feeling when something just ain’t right, and to act immediately when you feel that something is just “off.”
So I thought it would be super valuable for you to actually see what a thorough head to toe assessment looks like.
I have written it as a transcript that you can actually follow when you’re at school or clinical.
Please note: The words in bolded italics are the things you will say. The rest are just explanations and things you will do.
Ready? Let’s do this.
The General Survey
*Knock on the door, open the door, and provide privacy (either close the door or close the curtain)*
Hello, Mrs./Mr. _____, my name is _____ and I’m a student nurse. I’ll be helping out your nurse to take care of you today. Is that alright?
Great. I’m just going to wash my hands over here and then I’ll just take a listen to your heart, lungs, and tummy and see how you’re doing today. (Wash your hands)
While you’re washing your hands: Can you hear me alright? Am I talking too quietly? (This is your first test for hearing, and to make sure they can actually hear you)
I have just a few routine questions I need to ask before we get started. They’ll help me take the best care of you that I can.
Can you tell me what day of the week it is? (Establishes that they are alert and oriented (A&O) to time)
Great, can you tell me where you are? (Establishes that they are alert and oriented (A&O) to place)
Wonderful. So what brought you here? (Establishes that they are alert and oriented (A&O) to the situation)
By now you will be finished washing your hands. Put on gloves. Walk over to their bed and take a look at their name bracelet.
And can you tell me your name and date of birth please? I know you’ve already done this a million times already, but I will check every time I come in just to make sure I’m giving you what YOU need and not someone else’s. (Establishes that they are alert and oriented (A&O) to person)
CRITICAL POINT: You must use at least 2 patient identifies to verify their identity: having them verbalize their name and birth date, as well as looking at their wrist band is the easiest.
Are you in any pain at all right now?
If yes: Where does it hurt?
On a scale from 1 to 10, with 1 being hardly any pain and 10 being the worst pain you’ve ever felt, how would you rate it?
Can you describe the pain for me? Is it shooting, burning, aching, radiating, pins and needles?
Do you use anything to get around, like a walker, wheelchair, or cane?
Are you able to do things like cook, bathe, brush your hair, and brush your teeth? Or do you usually have someone help you with that?
Physical Assessment
Alright, thanks for answering all of my questions. I know it was a lot.
So now I’m just going to look you over a bit, see how you’re doing, and listen to your heart, lungs, and tummy. I will keep you covered as much as I can, and please let me know if you have any new pain at all during this process.
Head:
I’ll start at your head up here.
Feel their head for symmetry, shape, lumps, bumps, and bruises. Inspect their hair, and note the color, amount and distribution. Take a look at their face to look for symmetry and any missing facial features.
Eyes:
Now I’m going to take a peek into your eyes. Do you wear contacts or glasses? Is your vision clear?
I’m just going to pull down your eyelids a bit here. Gently pull down their eyelids and look at their conjunctiva. Note the color and if it is moist or dry.
Now I’m going to make sure your pupils are doing what they should be doing. So I have a little light here and I’m going to shine it twice into each eye. (This checks for pupil constriction and consensual constriction)
Now, can you focus on my penlight as I bring it to your nose? (This checks for accommodation)
Please note: Pupil constriction, consensual constriction, and accommodation gives you PERRLA (pupils are equal, round, reactive to light, and accommodation)
Ears:
Now I’m going to take a peek into your ears.
Do you wear hearing aids? (Throughout the assessment, note if they show signs of not being able to hear you very well: asking for you to repeat yourself, talking loud, looking confused, etc).
Check their ears to make sure there is no redness or discharge, and that the skin is intact (especially if they are on oxygen, which can cause skin breakdown behind the ears).
Mouth:
Can you open your mouth for me please?
Shine your penlight to take a look at their cheeks, gums, tongue, and throat. Note if it is red, swollen, patchy, or anything else that’s not the normal “pink and moist.”
Do you wear dentures?
If yes: Are they uppers, lowers, or both?
Nose:
Take a look at their nose to check for symmetry.
Do you have a runny nose or are feeling stuffy at all?
I’m just going to take a quick look inside your nose. Check for discharge, redness, or anything abnormal.
Neck:
Now I’m going to feel your neck. Please let me know if you feel any discomfort or pain.
Palpate around their neck, check for swelling, tenderness, or pain.
Can you move your head to the right for me? Now to the left? Now up, and down? Did that cause any pain or discomfort at all?
I’m going feel your collar bone here. Gently check for skin turgor by gathering a little bit of skin between your thumb and index finger, right below their collar bone.
Arms and Fingernails
I’m going to feel your arms now.
If your patient is a woman, ask: Have you ever had breast surgery, including a mastectomy?
If yes, ask: Which side?
DON’T put a lot of pressure on that arm and DO NOT take a blood pressure on that arm. After your assessment, document in their chart that they had breast surgery on that side and follow facility policy on what to label in the room. Often times, you will put up a sign that says “No BP’s on ___ side.”
Gently feel their arms all the way down to their hands. Note any swelling that is present. Feel their radial pulses on both wrists, and note if the pulses are thready, weak, strong, or bounding, and if they are happening at the same time or not.
Check their fingernails for hygiene and nutrition (clean, trimmed, smooth, clear) and gently press on their fingernails to check for capillary refill.
Lungs:
Have you been coughing at all lately?
If yes: Is stuff coming up when you cough?
If yes: What color is it? Is it thick or thin?
I’m just going to pull down your gown a little here, I’ll keep you covered as much as possible.
Inspect their chest for symmetry and shape, and note the size of their costal angle.
Now I’m going to take a listen to your lungs. I’ll move my stethoscope to multiple places so that I can get a really good listen.
Check out this blog post for how to position your stethoscope during a lung assessment.
Each time you move your stethoscope to a new place, ask your patient: Please take a deep breath in, and out through your mouth.
Listen for a full respiratory cycle at each site. Note their breathing rhythm, effort and depth, as well as if their rib cage is moving symmetrically.
Note: Don’t count the patient’s respiratory rate during the lung assessment. Often times they are breathing abnormally because they are aware of their breathing. I like to check their respiratory rate during the cardiac assessment.
I’ll need to listen to your lungs on your back as well. Do you need help rolling over?
Have your patient roll over, take a listen to their lungs on their backside (again, having them breathe in and out through their mouth each time you move your stethoscope).
Inspect the skin on their back and bottom. Note if it is red, intact or not, bruised, moist, or anything else you see.
Alright, now let’s roll you back over.
Heart:
I’m going to listen to your heart now. You can just relax and breathe normally.
Check out this blog post for how to position your stethoscope during a cardiac assessment.
While you’re listening to the patients PMI (point of maximal impulse, a.k.a. the mitral valve stethoscope placement), count their heart rate for a full minute and their respiration’s for one full minute.
Move their gown back up.
Abdomen:
Now I’m going to take a look and a listen to your tummy. I’ll just pull up your gown a little bit here, but I will keep you covered as much as possible. (Keep their bikini area covered with blankets and pull up their gown enough to see their belly).
Is your belly tender at all?
Make sure to follow the correct assessment order when doing your abdominal assessment (inspect, auscultation, percussion, palpation).
Look at their belly first. Then listen with your stethoscope for 15 seconds in each quadrant. Then percuss with your fingers. And lastly, palpate by pressing lightly around their belly.
Move their gown back down.
Legs, Feet and Toenails:
Now I’m going to take a look at your legs and your feet.
Do you have any pain or discomfort in your legs or feet right now?
Palpate down their legs. Note if their skin is intact, if there are any bruises or swelling, if their leg hair is patchy or evenly distributed, and if you can see their veins.
Do you get leg cramps?
If yes: When do they happen? Is there anything that helps them go away: position changes, walking or sitting, or anything else?
Check their toenails for hygiene and nutrition (clean, trimmed, smooth, clear) and gently press on their toenails to check for capillary refill.
Feel their dorsalis pedis pulses at the same time (one on each foot) and their posterior tibialis pulses at the same time (one on each foot). Note if it is thready, weak, strong, or bounding.
Cover their legs back up.
Finishing Up:
Alrighty, we are all done. Thanks so much for your patience.
CRITICAL POINT: Make sure the bed is in the lowest position, it’s locked, the rails are up or down (depending on their safety plan), and that their call light is within reach.
Is there anything I can get for you?
If no: Alright. I will be back in later. You can use your call light if you need anything sooner. I’m the big red button on your call light (or whatever button it is at your facility).
Wash your hands.
Bask in the excitement that you just totally NAILED your head to toe nursing assessment.
And there you have it! Feel free to use this transcript as you go through your head to toe assessment. You’re going to rock it! 🙂
