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Head-to-Toe Nursing Assessment: Checklist to Conducting Full
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HEAD-TO-TOE
NURSING
ASSESSMENT:
CHECKLIST TO
CONDUCTING FULL
BODY
EXAMINATIONS

The nursing process is the cornerstone of

all nursing practice. It is a roadmap to
quality, holistic care that nurses
consistently o!er to their patients.
Assessment, the "rst step of this process,
is when the RN gathers data about a
client’s health state. Registered Nurses
later use this information to formulate a
diagnosis and identify the appropriate
nursing interventions to contribute to the
patient’s recovery.

In the assessment phase, one of the basic

yet crucial tools a nurse has at their
disposal is complete head-to-toe
assessment. This evaluation includes all
body systems and gives valuable
information about the patient’s overall
condition. 

In this guide, we’ll give you an overview of

the assessment process, as well as a
comprehensive step-by-step guide on
how to perform a head-to-toe
assessment. As you gain experience,
examining patients will become routine.
This checklist is the "rst step to help you
gather the professional con"dence
needed to perform evaluations. 

Let’s get started. 

Contents

1 What Is a Head to Toe Assessment?

2 What Methods of Examination Do You
Use in a Head to Toe Assessment?
3 How Do You Start an Assessment?
4 Head to Toe Assessment Checklist
5 Things to Keep in Mind While
Performing a Head to Toe Assessment
6 Last Thing on the Checklist: Are You
Ready to Become the Best Nurse You Can
Be?

What Is a Head
to Toe
Assessment?
If you’re still in nursing school or you’re
just getting started with your nursing
journey, you may ask yourself: What is a
head-to-toe assessment? What does it
include? How do I complete one?

Simply put, a head to toe assessment is

an exhaustive process that checks
the health status of all major body
systems
systems. It is a comprehensive physical
examination that shines a light on a
patient’s needs and problems. Performing
this assessment falls under an RN’s
duties, although sometimes a doctor or
EMT might also do it. For the most part,
head to toe assessments happen during
primary care visits or annual physical
exams. 

When a patient comes into the medical

facility with a particular complaint or
health issue, the more common approach
will be a problem-focused
assessment. This means that the
assessment process is "xated on speci"c
care goals: the health problem has been
identi"ed, so this type of examination has
a narrower scope. 

The head to toe assessment is the

opposite of that. It’s broader and
concentrates on all aspects of the body.
Its length will vary depending on the
patient and their overall health status. 

What Equipment Should you Have

Ready for a Head to Toe Assessment?
Nurses who perform head to toe
assessment must come in prepared.
Some of the fundamental pieces of
equipment you should organize before
conducting a head-to-toe evaluation are:

Gloves

Thermometer

Scale

Hight wall ruler

Penlight

Stethoscope 

Blood pressure cu!

Tongue depressor

Sterile objects, both soft and sharp

What Methods
of Examination
Do You Use in a
Head to Toe
Assessment?
There are several procedures for
performing a physical examination. While
inspecting a patient in detail, you will use
four main methods. We’ll describe brie$y
what they are and what they entail. 

Inspection
Always performed "rst, inspection also is
the most repeated method of
examination. You need to use your sight
and smell to check speci"c body areas for
normal color, shape, and consistency. 

Palpation
Touching the patient to sense
abnormalities on (or in) the body is known
as palpation. In the process of conducting
a head-to-toe assessment, you will
employ two kinds of palpation: light and
deep. Light palpation is gentle and gives
information about skin texture and
moisture, $uids, muscle guarding, and
some super"cial tenderness the patient
may be experiencing. On the other hand,
deep palpation explores the internal
structures of the body to a depth of four
to "ve centimeters. Using this technique,
RNs can learn more about organs and
masses’ position, shape, mobility, and
possible areas of discomfort. 

Percussion
This third technique requires the nurse to
tap on the patient’s body to produce
sound vibrations. These sounds can
con"rm the presence of air, $uid, and
solids. It can also pinpoint organ size,
shape, and position. 

Auscultation
The last method of examination is
auscultation. It implies listening to the
heart, lungs, neck, or abdomen to gather
information. Direct auscultation is done
with the unaided ear. Indirect auscultation
requires the presence of ampli"cation or
mechanical devices, such as a
stethoscope.

How Do You
Start an
Assessment?
The "rst thing you need to do before
starting an assessment per se is to build
rapport with the patient
patient. Introduce
yourself, explain what you will be doing,
ask what brings them to the doctor’s
o%ce. Address any questions they may
have before you begin. Ask if there’s
something you could do to make them
more comfortable, like changing the
room’s temperature or the lighting. It’s
essential to build a relationship with the
patient before the actual physical
examination begins. 

From the moment you walk into the room,

you should start making mental notes of
certain physical clues the patient might
display: 

Their general appearance (How does

their hygiene, dress, a!ect seem?)

Their posture (Do they seem to

experience problems sitting/standing?
Are they grunting during movement?)

Is their speech clear or slurred?

Are there any abnormal smells?

Their alertness (Can they answer

questions? Are they reluctant to
speak?)

Signs of distress (Do they seem visibly

confused, pale? Do they have
problems breathing? Are they avoiding
eye contact?)

Once you have established a relationship

with the patient, you can begin the
assessment. 

Head to Toe
Assessment
Checklist
In order to make it easier for yourself to
conduct the assessment, you can have a
checklist or an overview of all the things
you ought to examine. This section will
explore in detail what exactly is included in
this type of assessment, and it will equip
you with a step-by-step guide to
performing it.  

1. General Overview
First, you obtain a general overview of the
patient’s health state. These are the
details to keep an eye on in this phase of
the assessment. 

Collect their vital signs. (It’s

encouraged to ask permission before
touching a patient. Also, explaining
what you are doing/what assessment
you are performing will help the patient
feel more relaxed.)

Check heart rate

Measure blood pressure

Take body temperature

Pulse oxymetry

Respiratory rate

Check pain levels

Check hight and weight and calculate

their BMI

2. Hair/ Skin/ Nails

Once you have a general overview, you
can start from the top of the body and
make your way down. The assessment is
called head to toe for a reason. Some
things to look out for are:

Hair distribution(even/uneven)

Hair infestations (lice, alopecia areata)

Bumps, nits, lesions on the scalp

Tenderness on scalp

Tenderness, lumps on the skin

Lesions, bruising, or rashes on skin

Temperature, moisture, and skin

texture (is the patient pale, clammy,
dry, cold, hot, $ushed?)

Edema

Consistency, color, and capillary re"ll

of nails

Pressure areas

3. Head 
Shape is rounded, symmetrical

Upon palpation, no nodules, masses or

depressions are identi"ed

Face appears smooth and symmetrical

with no nodules or masses present.

4. Eyes
Check external structures

Assess eye symmetry

Check conjunctive and sclera 

Check for PERRLA 

Perform visual acuity test

Check eyes for drainage

Check vision with Snellen Chart

Check six cardinal positions of the

gaze

5. Nose
Palpate nose and check symmetry

Check septum and inside nostrils

Patency of nares (patient can breath

through each nostril)

Check sense of smell

Palpate sinuses

6. Mouth and Throat 

Check lips for color and moistness

Inspect teeth and gums

Examine tongue

Inspect the inside of mouth

Look at tonsils and uvula

Assess hypoglossal nerve by asking

patient to move tongue from left to
right

Check the patient’s ability to taste, to

swallow, and their gag re$ex

7. Ears
Inspect for drainage or abnormalities

Test hearing with whisper test

Look inside ear: inspect the tympanic

membrane and asses ear discharge

Tuning fork tests (Weber’s Test, Rinne

Test)

8. Neck
Check neck muscles to be equal in size

Palpate lymph nodes

Check head movements and whether

they happen with discomfort

Observe neck range of motion. 

Check trachea placement

Check shoulder shrug with resistance

9. Chest: Cardiovascular Assessment

Listen to the heartbeat. Areas where to
auscultate heart sounds: aortic,
pulmonic, Erb’s point, Tricuspid, Mitral

Palpate the carotid and auscultate

apical pulse

10. Chest: Respiratory Assessment

Auscultate lung sounds front and back

Observe chest expansion 

Ask abour e!orts to breathe/coughing

Palpate thorax

11. Abdomen
Inspect abdomen

Listen to bowel sounds in all four

quadrants

Palpate all four quadrants of the

abdomen to check for pain or
tenderness

Ask about bowel or bladder problems

12. Extremities
Assess range of motion and strength
in arms, legs, and ankles

Assess sharp and dull sensation on

arms and legs

Inspect arms and legs for pain,

deformity, edema, pressure areas,
bruises

Palpate radial pulses, pedal pulses

Check capillary re"ll on

"ngernails/toenails

Assess gait

Assess handgrip strength and equality

13. Back area

Inspect back and spine

Inspect coccyx/buttocks

Once you go through all these steps, the

assessment is complete. Let your patient
know that this stage of evaluation is over.
Make sure they don’t have any questions
or concerns. 

Things to Keep
in Mind While
Performing a
Head to Toe
Assessment
Document your findings 
Performing the head to toe assessment is
a vital part of the nursing process. So is
making sure you thoroughly document
your "ndings. Write down all relevant
information you get from the assessment
concise yet clear. Your observations,
translated in these notes, will make up the
core of the subsequent care plan. It may
be helpful to use a head-to-toe
assessment checklist to guarantee that
you remember all the essential
information and document it. 

Communicate efficiently 
E%cient communication is the
cornerstone of successful nursing care.
When performing a head to toe
assessment, you should make use of this
crucial skill. Ask for permission before
touching a patient, explain what you are
doing – and why. Create a space where
patients feel encouraged to ask
questions, express worries or concerns. 

Bilateral symmetry 
Generally speaking, the human body is
bilaterally symmetrical. Any unusual
symmetry you may observe during your
examination is worthy of further
consideration. Weakness on one side?
Less ability to move the limbs on one side
of the body? These could be indicators of
underlying neurological or
musculoskeletal issues, so keep an eye
for noticeable di!erences between the
body’s right and the left side.  

Last Thing on
the Checklist:
Are You Ready
to Become the