Head to Toe Assessment

The head to toe assessment is a full assessment of the body from head to toe. The purpose of the assessment is to evaluate a patient's overall health, get a baseline, and become aware of any physiological changes or issues across all body systems.

Steps of the Assessment

Introduction

1. The nurse introduces themselves.
2. The nurse closes the blinds or door to ensure patient privacy.
3. The nurse engages in hand hygiene (ie washing hands, hand sanitizer, etc)
4. The nurse checks patient identifiers (ie patient armband, asking name and date of birth,
5. The nurse explains the procedure to the patient.
6. The nurse checks any patient orders.
7. The nurse asks the patient if they have any questions before we get started.

Patient Interview

1. The nurse identifies the chief complaint in the chart and by asking the patient what brings them in today.
2. The nurse goes through past medical history.
   1. This includes past surgeries.
3. The nurse goes through family history.
4. The nurse goes through current medical history.
   1. The nurse identifies any patient allergies.
   2. The nurse identifies any patient medications.
   3. The nurse goes through social screening.
      1. Drugs
      2. Alcohol
      3. Smoking
      4. Sex
      5. Physical Safety
   4. The nurse identifies any social determinants of health.
      1. Insurance
      2. Vaccines
5. The nurse assesses the patient to be alert and awake or stupor and non-arousable.
6. The nurse assesses the patient to orientation.
   1. Person (can be identified by patient identifiers above)
   2. Time
   3. Place
   4. Location
   5. Situation
7. Verbalize that the assessment will be done on bare skin.