This cheat sheet provides a step-by-step guide to conducting a thorough head-to-toe assessment in a clinical setting. It covers essential techniques to evaluate a patient’s overall health, focusing on various body systems and ensuring accurate observations are made. Following these instructions will help you perform a comprehensive nursing assessment.
General Survey
Initial Steps
- Knock and provide privacy: Close the door or curtains.
- Introduce yourself: "My name is ___. I'm a student nurse helping to care for you today."
- Hand hygiene: Wash your hands while engaging the patient in conversation.
- Questions for orientation: Ask about the day, place, and reason for being there to assess orientation (A&O).
- Pain assessment: Ask about pain location, rating (1-10), and description (sharp, dull, etc.).
Patient Identification
- Use at least two identifiers: Ask for the patient's name and date of birth, and check their wristband.
Physical Assessment
Head
- Palpate the scalp: Check for lumps, symmetry, and tenderness.
- Inspect hair: Note color, texture, and distribution.
Eyes
- Check conjunctiva: Ensure it is moist and pink.
- Pupils (PERRLA): Assess for pupil constriction and accommodation with a penlight.
Ears
- Inspect ears: Look for redness, discharge, or signs of hearing difficulty (ask about hearing aids).
Mouth
- Inspect oral cavity: Use a penlight to check the gums, tongue, and throat. Look for signs of dryness or redness.
Nose
- Inspect for symmetry and discharge: Ask if the patient feels congested.
Neck
- Palpate for tenderness and swelling: Ask the patient to move their head in different directions.
- Check skin turgor: Pinch skin below the collarbone.
Upper Body
Arms and Fingernails
- Inspect for swelling: Feel for any abnormalities, and check radial pulses for strength.
- Check fingernail hygiene and capillary refill: Press on nails and observe how quickly color returns.
Lungs
- Auscultate lung fields: Listen to breath sounds on both the front and back. Ask the patient to take deep breaths at each site.
- Inspect chest symmetry: Note breathing effort, rhythm, and depth.
Heart
- Auscultate heart sounds: Listen at the PMI (point of maximal impulse) for a full minute and observe respiratory rate.
Abdomen
- Inspect, auscultate, percuss, and palpate: Look at the abdomen for abnormalities, listen for bowel sounds, and palpate lightly for tenderness.
Lower Body
Legs, Feet, and Toenails
- Inspect legs for swelling, bruising, or varicose veins.
- Palpate pulses: Check dorsalis pedis and posterior tibialis pulses bilaterally.
- Check toenail hygiene and capillary refill.
Finishing Up
Safety
- Ensure safety: Place the bed in the lowest position, make sure the call light is within reach, and wash your hands before leaving.
Tips and Sources
Useful Tips
- Communicate continuously: Keep your patient informed during the entire process to build trust and ensure cooperation.
- Document carefully: Record findings, especially critical points like pain levels, orientation, and any abnormalities.
- Practice often: The more assessments you do, the more confident and efficient you'll become.
Sources
- NursingSOS. "Ultimate Head-To-Toe Assessment Transcript".
- RegisteredNurseRN: Head-to-Toe Assessment Guide
- Nursing.com: Head-to-Toe Assessment Nursing Cheat Sheet
- SimpleNursing: Head-to-Toe Physical Assessment Guide
- NCBI: Comprehensive Physical Examination and Health Assessment