HEAD TO TOE ASSESSMENT SUMMARY  A head-to-toe assessment should be done each time you encounter a patient for the first time each shift (or visit, for home care, clinic or office nurses).

Which aspects are considered during a Head to Toe Assessment? This assessment includes assessment of the physical, emotional and mental aspects of all body systems as well as the environmental and social issues affecting the patient. The nurse needs to observe for all of these factors and ask questions as needed.

1. Assemble your equipment: Wash your hands. Greet and identify the patient. 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 observe the environment. As you assess the body by systems, observe for such things as non-verbal cues, mobility and ROM. Which are the 5 vital signs evaluated during a Head to Toe assessment?

2. HEENT/Neuro: A HEENT examination is a portion of a physical examination; it principally concerns the Head, Eyes, Ears, Nose and Throat. Head: Shape and symmetry; condition of hair and scalp Eyes: Conjunctiva and sclera, pupils; reactivity to light and ability to follow your finger or a light Ears: Hearing aids, pain? Speak in a whisper: can he/she hear you and comprehend? Turn away to make sure he/she isn’t reading your lips. Nose: Drainage, congestion, difficulty breathing, sense of smell Throat and Mouth: Mucous membranes, any lesions, teeth or dentures, odor, swallowing, trachea, lymph nodes, tongue

What is a HEENT/Neuro examination? What does HEENT stand for? What is evaluated while assessing the head? What is evaluated while assessing the eyes? What is evaluated while assessing the ears? What is evaluated while assessing the nose? What is evaluated while assessing the throat/mouth?

3. Level of Consciousness and Orientation: Is he/she awake and alert? Is he/she oriented to Person (knows his/her name), Place (he/she can tell you where he/she is) andTime (knows the day and date). A fourth level of orientation is Purpose (he/she knows why you are examining him/her; or knows the function of something such as your penlight or stethoscope).

What does Person mean? What does Place mean? What does Time mean? During the assessment of the Level of Consciousness and Orientation in a patient: What does Person mean? What does Place mean? What does Time mean? What does Purpose mean?

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.  The Integumentary system comprises the skin and its appendages (including hair and nails). 

4. Skin: What is the the Integumentary system? What must be assessed when looking at the skin?

5. Thoracic region: Assess lung and cardiac sounds from the front and back. Assess them for character and quality as well as for the presence or absence of appropriate sounds or lumps. Palpate the chest wall and breasts for any tenderness.

5. Thoracic region: Should lung and cardiac sounds be assessed from the front only? Which of the following sounds should be measured in lung and cardiac assessment? Why should the chest wall and breasts be palpated during assessment of the thoracic region?

6. Abdomen: Listen to bowel sounds throughout the 4 quadrants. Palpate for tenderness or lumps. Palpate the bladder. Ask about intake and output of bowels and bladder. Ask about appetite.

6. Abdomen: In which quadrant/s should bowel sounds be auscultated? Should the abdomen also be palpated for tenderness and/or lumps? Is it more important to ask the patient about bowel or bladder output? Is appetite an important factor when assessing the abdomen area?

What does ROM mean? 7. Extremities: Assess for temperature, capillary fill and ROM. Palpate for pulses. Note any edema, lesions, lumps or pain. ROM = Range of Motion What does ROM mean?

8. 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? SOB = Shortness of Breath What does the acronym SOB stand for?

9. Wash your hands. Document your findings. Report any significant changes or findings to the PCP (primary care practitioner). Example of Head to Toe Assessment form: http://aperiomlc.com/files/An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis_12_2008_Website.pdf