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 and Prepration

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.
   1. Speech and Hearing
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.

General Inspection

1. While conduction the nursing interview, the nurse should begin evaluation.
   1. Skin Color
   2. Facial Expression
   3. Mobility
   4. Dress and Posture

Vital Signs & Pain

Manual Blood Pressure

1. Apply correctly sized sphygmomanometer (blood pressure cuff) 2-5 cm (1-2 inches) above the brachial artery (the main artery of the upper arm)
2. Position patient with arm supported at heart level and feet flat on the floor.
3. Ask patient what their average blood pressure is.
4. Obtain the patient’s blood pressure:
   1. Put on the stethoscope with earpieces angled forward, place the diaphragm over the brachial artery & inflate cuff 30mmHg above estimated systolic pressure (top number) to avoid missing an auscultatory gap
   2. Deflate cuff 2mmHg per second while listening for Korotkoff sounds, noting when first Korotkoff sound appears (systolic BP) & the last audible Korotkoff sound (diastolic BP)(bottom number)
   3. Continue to slowly deflate the cuff for a bit longer to make sure the Korotkoff sounds don’t reappear, and then rapidly deflate the cuff

Head, Eyes, Ears, Nose, Mouth, Throat (HEENT)

Eyes

1. The nurse will examine various parts of the eye:
   1. Sclera (white outer layer of the eye)
   2. Conjunctiva (mucous membrane that covers the white part of the eye)
   3. Pupil Size
   4. Pupillary Response (shining pen light into the eye and observing the response)

Nose

1. The nurse will examine various parts of the nose:
   1. Nares (nostrils)
      1. Check to ensure nasal passages are open and unobstructed
      2. Check for congestion/drainage.

Mouth

1. The nurse will examine various parts of the mouth:
   1. Check to make sure the mucous membranes are smooth, moist, and observe color