Head-to-Toe Assessment
Student Skill Requirements
Introduction/Pre-Assessment Needs
*Wash Hands — Student verbalizes washing hands for 20 seconds.
*Gloves — Student dons clean gloves.
*Introduction — Introduces self as a student nurse with CNI College.
Identify Patient— Student identifies patient by checking arm band against patient verbalization of name
and date of birth.
*Explain Procedure/Consent – Explains procedure and time required. Obtain verbal consent from patient.
*Scan Room — Student verbalizes inspection of room for cleanliness/safety issues/status of equipment.
Script:
Knock, (patient says “come in”)
*Scan the room for safety (Room is safe)
*Wash your hands for 20 seconds and
*introduce yourself.
“Hi my name is _____, I am a student nurse with CNI College, I will be helping your nurse today.”
*Explain the procedure
“I am here to perform a head-to-toe assessment and document how you are feeling. Is this okay with you?” [Consent obtained]
*Glove up and ask to see the patient’s armband.
“May I see your armband?” (Patient says yes.)
“Can you tell me your name?” (Ms/Mr ____)
“Can you tell me your date of birth?” (00/00/0000)
“Do you know what day it is?”
“Do you know where you are?” ( At the hospital.)
“Do you know why you are here?” ( I had a UTI)
(Verbalize patient’s General appearance.)
Example
“Patient seems to be in stable condition, not in pain or in shortness of breath.”
General Inspection
(This was done above⬆️)
General Appearance — Student verbalizes general appearance of patient
LOC/Orientation — Student verbalizes level of consciousness. Student asks patient to verbalize person,
place, time, and purpose.
Review Comfort
*Difficulty Breathing — Student will assess if patient is in any respiratory discomfort
*Assess for Pain — Student will verbalize assessing for pain. Will verbalize pain on a scale of 0-10.
*Restroom Needs — Student will ask patient the need for the restroom before beginning head-to-toe.
*Provide Privacy— Student will close curtain or verbalize providing patient privacy.
Script:
(Now it’s time to ask some brief questions before getting started on the head-to-toe assessment.)
“Before we begin the assessment I just want to ask you a few questions.”
“*Are you having any difficulty breathing at the moment? (No.)
*On a pain scale of 0 – 10, where 10 is the worst pain. Where is your pain? (0)
*Do you need to use the restroom before we begin the head-to-toe assessment? (No thank you.)
Okay great, let’s get started(*For privacy, close the curtain.)
Face/Head/Neck/Shoulders
Hair/Scalp — Student assesses hair/scalp for any infestation. Inspects scalp for abnormalities.
Skin — Student assesses skin for breakdown, redness, injuries. Assesses and verbalizes skin color,
moisture, and temperature.
Inspect Ears — Using penlight, inspect ears for drainage. Inspect ears and behind ears for skin
breakdown.
Hearing — Student askes patient if they have any difficulty hearing.
Facial Symmetry— Student assess facial symmetry by asking patient to smile and asks patient to raise
eyebrows.
Periorbital Edema — Student assesses and verbalizes any findings of periorbital edema.
Eyes — Using pen light, student assesses PERRLA and cardinal fields. Students asks if patient wears
glasses or contacts.
Nose/Patency— Using penlight, student inspects nose for drainage and patency.
Mouth — Student inspects mouth and verbalizes condition of lips, mucous membranes, teeth, gums, and
tongue, Student asks patient if they have difficulty chewing and if they wear any dentures.
Speech —Student verbalizes whether patient’s speech is clear, flowing, non-slurred.
Inspect Neck/ROM — Student inspects for masses, goiter, verbalizes checking ROM by asking patient to
move head from side-to-side.
Assess for
JVD— Student inspects and verbalizes assessing for JVD.
Script:
“Thank you for answering my questions”
“Now I’m just going to look you over a bit. To see how you’re doing, I will listen to your heart, lungs, and check your body. I will keep you covered as much as I can, and please let me know if you have any new pain at all during this process.”
Head(Hair and Scalp):
“I’ll start at your head up here.”
Feel their head for symmetry, shape, lumps, bumps, and bruises. Inspect their hair, and note the color, amount, and distribution. Check for infestations.
(Verbalize that you are looking for infestations of the hair(lice) to the professor in check-offs. Never to the patient.)
Eyes:
“Now I’m going to take a peek into your eyes. Do you wear contacts or glasses? Is your vision clear or blurry?”
(Verbalize/Checking for Periorbital Edema)
“I’m just going to pull down on your eyelids a bit here.” (open eyes)
(Gently pull down their eyelids and look at their conjunctiva. Note the color and if it is moist or dry.)
“Now I’m going to make sure your pupils are doing what they should be doing. I have a little light here and I’m going to shine it into each eye. Don’t look directly into the light, focus your eyes on my nose as I shine the light.”
(This checks for pupil constriction and consensual constriction)(Verbalize that the patient’s pupils are PERRLA[pupils are equal, round, reactive to light, and accommodation])
“Now, can you focus your eyes on my penlight without moving your head as I move it around?”
(While your penlight is off, Check cardinal fields. This checks for accommodation)
Nose:
Take a look at their nose to check for symmetry.
“Do you have a runny nose or are feeling stuffy at all?
I’m just going to take a quick look inside your nose. “
Check for discharge, redness, or anything abnormal.
Ears:
“Now I’m going to take a peek into your ears.
Do you wear hearing aids?”
(Throughout the assessment, note if they show signs of not being able to hear you very well: asking for you to repeat yourself, talking loud, looking confused, etc).
Check their ears to make sure there is no redness or discharge, and that the skin is intact (especially if they are on oxygen, which can cause skin breakdown behind the ears).
Mouth:
“Can you open your mouth for me please?”
(Shine your penlight to take a look at their cheeks, gums, tongue, and throat. Note if it is red, swollen, patchy, or anything else that’s not the normal “pink and moist.” State the color of the patient’s lips, if normal say pink.)
Do you have any problems chewing?
“Do you wear dentures?”
If yes: Are they uppers, lowers, or both?
Speech:
(State the patient’s speech. You can say its clear, flowing, and non-slurred)
Check Facial Symmetry:
“Can you smile? Can you raise your eyebrows?”
(State the patient has no facial droop and face is symmetrical )
Neck:
“Now I’m going to feel your neck. Please let me know if you feel any discomfort or pain.”
Palpate around their neck, and check for swelling, tenderness, or pain.
**Assess for JVD(Jugular Vein Distention)
“Can you move your head to the right for me? Now to the left? Now up, and down? Did that cause any pain or discomfort at all?”
(Checking for ROM[Range of motion])
Upper Extremities
ROM — Student checks and verbalizes flexion/extension of shoulders, elbows, wrists and verbalizes
findings.
IV Access — Student verbalizes assessment and findings of IV inspection. Student verbalizes assessing for
redness, drainage, and infiltration.
Skin — Student assesses skin and verbalizes any findings.
Grip Strength — Student assesses grip strength bilaterally by having patient squeeze two fingers.
Radial Pulses —Student checks equality and regularity of radial pulses, grades radial pulses and
verbalizes findings.
Capillary Refill — Student depresses nail bed, releases and notes time for color to return. Student
verbalizes findings.
Script:
Arms:
“Can you shrug your shoulders for me please?”
(Checking for a range of motion of the shoulders.)
Can you raise your arm for me?
Can you Flex your arm?
Can you extend your arm?
(verbalize ROM is good, or at a scale of 0-5. 5 is a normal)
“I’m going to feel your arms now.”
-Gently feel their arms all the way down to their hands. Note any swelling that is present. (Verbalize any findings)
-Check IV access for any redness, drainage, and infiltration. (Verbalize)
“I’m going to feel for your pulse.”
-Feel their radial pulses on both wrists, and note if the pulses are thready, weak, strong, or bounding. (Verbalize strong)
“Can you grasp my fingers with your hands and squeeze.”
-Checking for grip strength. (Verbalize grip strength is normal)
“I’m going to squeeze on your fingernails to check for oxygenation.”
-Gently press on their fingernails to check for capillary refill. (Verbalize it’s normal)
Trunk/Cardiac/Respiratory
Skin — Student inspects skin for breakdown or injuries. Student checks skin turgor and verbalizes
findings.
Symmetry —Studnt inspects thoracic cage for symmetry and verbalizes findings.
Heart Sounds — Student auscultates heart sounds and verbalizes S1 at apex and S2 at base. Identifies
rhythm and verbalizes findings.
Apical Pulse — Student locates apical area at left 5th intercostals space, left mid-clavicular line. Verbalizes
listening for 1 minute. Verbalizes findings.
Anterior/Lateral Lung Sounds — Student auscultates anterior and lateral lung fields in 8 areas, compares
right and left sides, and moves stethoscope appropriately. Student verbalizes findings.
Respiratory Pattern — Student notes and verbalizes respiratory pattern.
Respiratory Conditions — Student verbalizes asking patient if they have a cough with or without sputum,
smoke or use any other substances. Inquires about use of home 02.
Script:
Chest:
Inspect the patient’s skin for any skin breakdown.
“I’m going to feel your collar bone here.”
Gently check for skin turgor by gathering a little bit of skin between your thumb and index finger, right below their collar bone.
Look for symmetry in the thoracic cage.
(Verbalize Findings)
Heart:
I’m going to listen to your heart now. You can just relax and breathe normally.
Auscultate S1 and S2
Auscultate for the Apical Pulse.
Verbalize you will count their heart rate for a full minute.
Lungs:
“Have you been coughing at all lately?”
If yes: Is stuff coming up when you cough?
If yes: What color is it? Is it thick or thin?
“Do you smoke or use any other substance?”
“I’m just going to pull down your gown a little here, I’ll keep you covered as much as possible.”
Inspect their chest for symmetry and shape, and note the size of their costal angle.
“Now I’m going to take a listen to your lungs. I’ll move my stethoscope to multiple places so that I can get a really good listen.”
Each time you move your stethoscope to a new place, ask your patient:
Please take a deep breath in, and out through your mouth.
Listen for a full respiratory cycle at each site. Note their breathing rhythm, effort and depth, as well as if their rib cage is moving symmetrically.
Abdomen/Elimination
Inspection — Student inspects and verbalizes contour of abdomen.
Bowel Sounds — Student auscultates beginning in RLQ progressing to RUQ to LUQ to LLQ and verbalizes
findings.
Palpation —Student lightly palpates abdomen and verbalizes findings.
Perineal Area — Student inspects perineal area for cleanliness and skin redness/breakdown. Student
verbalizes findings.
Last BM—Student inquires about patient’s last BM. Dates, normal/abnormal.
Nausea/Vomiting — Student verbalizes inquiry.
Diarrhea/Constipation – Student verbalizes inquiry.
Bowl Incontinence – Student verbalizes inquiry.
Urine Output – Student verbalizes inquiry.
Color/Odor– Student verbalizes inquiry.
Burning/Urgency/Frequency – Student verbalizes inquiry.
Urinary Incontinence – Student verbalizes inquiry.
Script:
Abdomen:
Now I’m going to take a look and listen to your tummy. I’ll just pull up your gown a little bit here, but I will keep you covered as much as possible. (Keep their private area covered with blankets and pull up their gown enough to see their belly).
Is your belly tender at all?
Make sure to follow the correct assessment order when doing your abdominal assessment (inspect, auscultation, palpation, percussion).
-Look at their belly first.
-Then listen with your stethoscope for 15 seconds in each quadrant.
-Start on the RLQ
Next the RUQ
Next the LUQ
And lastly the LLQ
-Then, palpate by pressing lightly around their belly.
-Lastly. And maybe optional, percuss lightly with two fingers.
Move their gown back down.
“I am going to check your private area. Is that okay?”
Now check the Perineal Area.
(verbalize findings: Inspects perineal area for cleanliness and skin redness/breakdown. )
Questions to ask:
Do you have feelings of any Nausea/vomiting?
Have you had diarrhea or constipation?
When was your last Bowel Movement(BM)?
When did you last Urinate?
What was the color? Is there any burning sensation?
Are you able to control when you need to go to the restroom? (Urination Incontinence: Bladder and bowel control)
Lower Extremities
ROM — Student checks for flexion/extension of hips, knees, ankles and verbalizes findings and verbalizes
a grade on 0-5 scale.
Falls/Assistive Devices — Student askes the patient if they have fallen within the last 6 months. Students
askes patient if they use any assistive device to while ambulating.
Skin – Student inspects skin for breakdown or injuries and verbalizes findings.
Feet/Color/Temp/Integrity – Student inspects skin color and integrity of feet/between toes/toes and
nails. Student verbalizes findings.
LE Pulses — Student locates, grades, and checks equality of dorsalis pedis and posterior tibial pulses and
verbalizes findings.
Edema — Student depresses skin over dorsum of foot, ankle, and tibia for 5 seconds and releases.
Student verbalizes findings. If pitting is present, student verbalizes grade on a 1-4 pitting edema scale.
Sensation — Student instructs patient to close their eyes then lightly touches skin in a random order of
sites on both legs. Student instruct patient to say “now” when touch is felt. Student compares
symmetric points and verbalizes findings.
Script:
Legs, Feet and Toenails:
Now I’m going to take a look at your legs and your feet.
Do you have any pain or discomfort in your legs or feet right now?
Palpate down their legs. Note if their skin is intact, if there are any bruises or swelling(Pitting EDEMA).
Have you had any falls in the last 6 months?
Do you use any assistive devices, like a cane or a walker?
-Feel their dorsalis pedis pulses at the same time (one on each foot) and their posterior tibialis pulses at the same time (one on each foot). Note if it is thready, weak, strong, or bounding.
-Check for capillary refill.
-Check for sensation.
Can you close your eyes for me please? I am going to touch your legs and feet in different spots. Without looking, let me know you feel my touches by saying “Now” when I touch you.
Cover their legs back up.
Posterior(Back)
Posterior/Lateral/Lung Sounds — Student auscultates posterior and lateral lung fields in 8 areas.
Compares right and left sides and moves stethoscope correctly. Student verbalizes findings.
Spinal Alignment/Posture— Student identifies and verbalizes spinal curvature using appropriate terms
(straight/aligned vs. kyphosis/lordosis/scoliosis).
Skin – Student inspects skin for color, temperature, breakdown or injuries and verbalizes findings.
Sacral Edema — Student palpates sacral area for edema and verbalizes findings.
Safety
Script:
“I’ll need to listen to your lungs on your back as well. Do you need help rolling over?”
Have your patient roll over, take a listen to their lungs on their backside (again, having them breathe in and out through their mouth each time you move your stethoscope).
*There are 8 points to auscultate.
Inspect their spine for symmetry.
Inspect the skin on their back and bottom. Note if it is red, intact or not, bruised, moist, or anything else you see.
Check for any Sacral Edema, Pressure sores.
“Alright, now let’s roll you back over.”
Finals Steps
Do You Feel Safe? — Student assesses for patient feeling safe in hospital by asking patient if they feel
safe at the hospital. Student assesses for possible abuse by asking “do you feel safe at home?”
Assess for Harm — Student assesses patient for harm to self or others. Student verbalizes “do you have
an intent to harm yourself or harm others?”
Bed in Low Position — Student ensures bed is in low position.
Side-Rails Up — Student ensures side-rails are up.
Brake On — Student ensures bed brake is on.
Call Light in Reach — Student ensures shows call light to patient and places light near patient verbalizing
“your call light is here, please call if you need anything.”
Possessions in Reach — Student verbalizes patient possessions are in reach.
Closure
Anything Else? — Student asks patient if there is anything they would like to mention.
Any Questions? Student asks patient if they have any questions.
Reposition — Student ensures patient is comfortable.
Thank the Patient — Student thanks the patient before leaving the room.
Doff Gloves/Wash Hands — Student doffs clean gloves and washes hands for 20 seconds.
Script:
Okay, we are almost done. I just have a few last questions.
Do you Feel safe at the hospital?
Do you feel safe at home?
Do you feel like harming your self?
Do you feel like harming others?
Alrighty, we are all done. Thanks so much for your patience.
CRITICAL POINT: Make sure the bed is in the lowest position, it’s locked, the rails are up or down (depending on their safety plan), and that their call light is within reach.
Is there anything I can get for you?
If no: Alright. I will be back in later. You can use your call light if you need anything sooner. Press the big red button on your call light and I or another nurse will come in to help you with whatever you need.
Wash your hands.
Document.