Head to Toe Assessment

Department of Nursing Education Services

 Learning Objectives
By the end of the session learner will be able to:
• Discuss the head to toe assessment and its purpose
• Learn basic principle of head to toe assessment
• Apprehend head to toe – systematic approach
• Interpret VIP Scoring, Morse Scale, Braden scale
 Head to toe assessment
• A head to toe assessment is the baseline and ongoing data that is
needed on every patient. Once a systematic technique is
developed, the assessment can be completed in a relatively short
period of time.
• Assessment needs to be done at the beginning of each shift, and
at regular intervals during the shift. Since many healthcare
professionals works more than 8 hour shifts, assessment needs to
be done more than once on basis of patient’s need.
 Purpose
Physical assessment of a patient serves many purposes:
1. Screening of general well-being. The findings will serve as
baseline information for future assessments.
2. Validation of the complaints that brought the patient to seek
health care.
3. Monitoring of current health problems.
4. Formulation of diagnoses and treatments.
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Key Tips
• Stand on the right side of the patient; establishing a dominant
side for assessment will decrease your movement around the
patient.
• Perform the assessment in a head-to-toe approach.
• Always compare the right- and left-hand sides of the body for
symmetry.
• Proceed from the least invasive to the most invasive procedures
for each body system.
• Always perform the physical assessment using a systematic
approach; if it is performed the same way each time, you are
less likely to forget some part of the assessment.
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Preparatory phase
Before beginning your assessment, take these steps:
• Make sure the room is quiet, well-lit, and warm.
• Obtain a stethoscope with a bell and a diaphragm. Disinfect the
stethoscope before use.
• Assemble equipment before entering the room
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Introduction to the client

• Identify patient correctly using two identifiers (Name and
Medical Record Number)
• Explain procedures to patient.
• Take verbal consent from the patient.
• Provide privacy.
• Perform hand hygiene.
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Step 1: General Survey

• Check Level of Consciousness (LOC) – Alert, Responsive to
Voice, Responsive to Pain, Unresponsive
• Orientation
• Time
• Place
• Person
• Self
(Note: always use open ended questions)
• GCS – if altered LOC
• Assess gait
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Glasgow Coma Scale (GCS)

assessment

https://www.youtube.com/watch?v=v6qpEQxJQO4&t=2s
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Assess Gait
• Observe patient gait (can be done when patient gets up for
washroom).
• It should be symmetrical, regular, and balanced.
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Step 2: Examine Head and Neck

• Head
• Eyes
• Nose
• Ear
• Mouth
• Neck
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Head
• Inspection:
• Check distribution and condition of hair
• Check scalp for bumps, nits, lesions, etc.
• Palpation:
• skull for tenderness
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Eye Assessment
Inspection:
• Eye brows and Eye Lashes: for
hair distribution and for symmetry
• Conjunctiva and Sclera : Look for
color and any unusual discharges
• Pupils: Pupil size and reaction
(Brisk, Sluggish, Fixed)

Note: For pupil Assessment - Keep

environment dark and use torch
light for better visualization
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Nose
Inspection
• External nose : Symmetry of nostrils and deviated nasal septum
• Internal nose: Polyps and other abnormality
Palpation
• Palpate for tenderness
Special Test: Nasal patency
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Ears
• Inspect and palpate auricle for lesions, tenderness
• Look inside ear; assess ear for cerumen (wax) or discharge
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Mouth assessment
• Inspection

• Check for Gag Reflex

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Neck
Assess Trachea for deviation
• Palpation: palpate neck to feel for any lumps, deviations, or
tenderness in the neck, especially the tracheal region
Check Carotid Pulse
• Check carotid pulses one by one: check amplitude and regularity
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Step 3: Cardiac assessment

Video Link: https://www.youtube.com/watch?v=Qt_4-

aXizDo&list=PLLKSXV1ibO84CYCBFE-h9dzr0oC1NJA_6&index=2

Note: Ask patient to breathe normally

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Step 4: Respiratory Assessment

• Inspect anterior and posterior chest
for lumps, asymmetry, lesions, etc.
• Inspect chest rise and fall
Note: please look for flail chest or
abnormal movement. Also, inspect the
use of accessory muscles or work of
breathing.
• Check for air entry bilaterally
• Auscultate breath sounds
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Characteristics of Breath sounds

Breath Location
Sounds

Bronchial Trachea and Larynx

Bronchove Major bronchi, between

sicular Scapulae, Upper Sternum
and second ICS
Vesicular Peripheral Lung Fields

https://www.youtube.com/watch?v=64bLgnv1mHA
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Step 5: Abdomen Assessment

• Inspection
• Look for shape and stoma
• Auscultation
• Bowel sounds- in all 4 quadrants
• Palpate
• Soft Palpation
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Step 6: Genito-Urinary Assessment

• Check for:
• Spontaneous urine output
• Foley’s catheter
• Suprapubic catheter
• External catheter
• Color (Amber, yellow, hematuria)
• Clear/ turbid urine output
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Step 7: Upper and Lower Extremities

Bilateral checks for comparison need to be
done for upper and lower extremities.
Inspect skin for
• Any abnormality (redness/bruises)
• Color
• Texture
Palpation:
• Turgor
• Temperature
• Edema
• Capillary refill
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Upper and Lower Extremities- Cont

Radial
Check amplitude and regularity of: Pulse
• Radial and brachial pulse
• Dorsalis pedis and posterior tibial
Palpation of Pulse (Four point Scale) Brachial
Pulse
4+ Full, bounding
3+ Increased/ Strong
2+ Normal
1+ Weak, thread
Dorsalis Posterior
0 Absent Pedis tibial
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Upper and Lower Extremities- Strength

• Hand strength - have patient grip two of your fingers at the same
time. Check bilaterally for equality in strength.
• Leg strength - place your hands on the patient's sole. Have the
patient push legs against the resistance of your hands. Check
bilaterally for equality in strength.
Grade Description
0 No muscle activation
1 Trace muscle activation, such as a twitch, without achieving
full range of motion
2 Muscle activation with gravity eliminated, achieving full range
of motion
3 Muscle activation against gravity, full range of motion
4 Muscle activation against some resistance, full range of motion
5 Muscle activation against examiner’s full resistance, full range
of motion
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Upper and Lower Extremities

Range of Motion (ROM)
• Active Vs. Passive
• Check for following
• Abduction
• Adduction
• Flexion
• Extension
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Assess Peripheral Access or Central Line

• Site and Gauge
• Condition of site (Visual Infusion Phlebitis Score)
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Step 8: Back and Sacrum

• Examine back, sacrum, occipital area, buttocks and trochanter
region for skin breakdown, bruising, redness or pressure injury.
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Step 9: Braden Scale (assess for skin

integrity)
What is the Braden Scale?
• Scoring system
• Evaluates patient’s risk of developing a pressure ulcer
• Braden Scale – most preferred tool
• Six categories assessed

Why it is important to assess risk of Pressure Ulcer (PU)?

• Significant problem in older hospitalized adults
• PU and treatment negatively affect every dimension of patient’s life
• Expensive to treat
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Step 10: Morse Scale

Variables Numeric Values Score
1. History of falling (Acute fall within 3 months) No 0
_______
Yes 25
2. Secondary diagnosis (More than 1 diagnosis) No 0
_______
Yes 15
3. Ambulatory aid (Mark only one response/ use the highest score)
None/bed rest/wheel chair/nurse assist 0
Crutches/cane/walker 15
Furniture 30 _______

4. IV/ Heparin/ Saline Lock (Mark yes if present) No 0

_______
Yes 20
5. Gait/ Transferring (Mark one response/ use the highest score)
Normal/bed rest/Immobile 0
Weak 10
Impaired 20 _______

6. Mental status
Oriented to own ability 0
Overestimates or forgets limitations 15 _______
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References
• https://www.primaris.org/sites/default/files/resources/Restraints%20and%20Falls/falls_morse%20fall%20scal
e%20final.pdf
• https://lms.rn.com/getpdf.php/2051.pdf
• http://www.delmarlearning.com/companions/content/1401872069/About%20the%20book/sample%20chapter.
pdf
• https://lms.rn.com/getpdf.php/2047.pdf
• https://slideplayer.com/slide/10324665/
• https://www.slideshare.net/BPfanpage/basic-headtotoe-assessment?next_slideshow=1
• https://jessbrantnerwvudietetics.wordpress.com/2014/01/23/what-is-the-braden-scale/
• https://www.phca.org/wp-content/uploads/2016/01/webinar-20140805.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3524381/
• http://www.neuroexam.com/neuroexam/content4.html
• https://www.ncbi.nlm.nih.gov/books/NBK436008/
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She must have a respect for her own calling, because

God’s precious gift of life is often literally placed in
her hands; she must be a sound, and close, and
quick observer.
—Florence Nightingale