A nurse is preparing to conduct a head-to-toe assessment on a client in an outpatient setting

Nursing assessments are fundamental in your day-to-day. As a nurse, patient interactions differ widely in scope within different units, the ED, ICU, on the floor, and so forth. How you complete the assessment and how much detail to go into will also vary depending on which step in a patient’s recovery process, such as between outpatient or inpatient. In all assessments, your goal is to be thorough, providing consistent care to patients across the board. There are several types of nursing assessments that are fundamental, head-to-toe nursing assessments, and focused assessments. We will go over how to know which one to use and contextualize how assessments are prepared in different stages of care. Comprehensive health assessment training is one of many essential components of a nurse’s education. Building confidence in this area continues throughout your nursing career. Seeking out more seasoned nurses as mentors is a good strategy for those who are new to the field.

Head-to-Toe Nursing Assessment

A head-to-toe assessment is a physical exam or health assessment. It’s one of the many important tools under your belt. This assessment helps you understand a patient’s needs and problems by giving a detailed examination. Typically, that includes a thorough health history and head-to-toe physical exam of all major body systems (this is where it gets its name). These kinds of assessments are performed by registered nurses for patients admitted to the hospital or in community-based settings (i.e. home visits), EMTs, physicians’ assistants, and on occasions, doctors. Nurse practitioners can also perform complete assessments during annual physical examinations. It’s not practical to perform this in all settings, but it is a key component to primary care visits and annual checkups.

Focused Nursing Assessment

A detailed nursing or focused assessment involves having a care goal in mind, and aims at solving a problem, often with one or multiple body systems. This is where you will utilize your clinical judgment to decide which elements of a focused assessment are relevant to your patient. For an ICU nurse, for example, your focused assessments generally revolve around a specific body system such as the respiratory or cardiac system. While the entire body is important there is usually not enough time for a detailed full-body assessment. A focused assessment is also usually done on stable patients. For example, you will find this type of assessment done more often in a controlled setting (inpatient and outpatient generally). This is used when a patient presents a specific complaint or issue. This is the key difference between a head-to-toe versus a focused – that there is a care goal in mind.

Preparing for the Head-to-Toe Nursing Assessment

Some tools that may be useful during a head-to-toe nursing assessment include:

• Penlight
• Blood pressure cuff
• Thermometer
• Tongue depressor
• Stethoscope
• Sterile sharp object (like toothpick or pin) for assessing extremities
• Sterile soft object (like a cotton ball) for assessing extremities
• Something for the patient to smell (could be an alcohol swab)

General Guidelines for a Nursing Assessment

These guidelines are relevant to both head-to-toe nursing assessment and focused assessments.

Most head-to-toe nursing assessments run around 30 minutes. The length of focused assessments varies. As you are preparing for an assessment, keep in mind any part of the visit that may require exposing yourself to blood or body fluids. Practice safe handling and cleanliness with any equipment involved.

In both assessments, a patient’s history is taken into consideration. In a focused assessment, the nurse may want to question the patient on specific history questions related to their body system being examined (i.e. history of broken bones in their body or immediate areas). A patient history includes any information relating to the current complaint or condition, as well as past medical problems that could be related. If family (for inpatient or outpatient) or bystanders (for an ER unit) are there, they can also be a source of information. We use the “SAMPLE” acronym when remembering the important parts of a patient’s history

S – Signs/symptoms

A – Allergies

M – Medications

P – Pertinent past medical history

L – Last oral intake

E – Events leading to the illness. This is also known as an injury rapid assessment – this a quick, less detailed head-to-toe assessment of the most critical patients. You may not find this as relevant if you are not working in critical care or an emergency unit.

Non-verbal Cues Just as Important

While much of a nursing assessment focuses on biological or physiological attributes and active listening, nurses also need to be able to pick up on certain non-verbal cues. Sometimes, what a patient doesn’t say is the most critical piece of information. Non-verbal cues like a patient’s avoiding eye contact or reluctance to answer questions can enlighten a nurse to other issues and history.

The amount of time required to complete a health assessment depends on the type of assessment and the patient’s overall health status. It’s important not to rush the process. As you are gathering information, it’s vital that the standard of evaluation be held and not rush. Missing an abnormality, like a cancerous mole, or missing neurological red flags can be disastrous. Nurses bear the responsibility of identifying anomalous symptoms and accurately documenting them for the future care of patients with a physician.

Physical Non-Verbal Cues To Watch

These cues overlap with other systems in your body. Examining the skin is a great litmus test of overall wellness. Take note of the following:

• any unusual coloring (or lack of) in your patient’s skin
• whether it is cold, hot, clammy, or dry anywhere throughout the exam
• any lesions, abrasions, or rashes

A physical non-verbal cue to check on patients is bilateral symmetry (i.e., the left side is the same as the right side). When examining a patient, make note of any unusual asymmetry. For example, noteworthy cues to unusual asymmetry may be:

• weakness on one side of their body
• limited range of motion
• one side is limper from the other side

Building Rapport

Begin an assessment by building trust and respect. Assessing your patient’s comfort, and making it so they are comfortable without unnecessary touching is part of the beginning of an assessment. There is no need to overdo it, but make sure that they are relaxed. During this introduction, you are also noting non-verbal cues and your patient’s overall mannerisms. Some aspects of a patient’s demeanor you might want to be aware of may be:

• level of alertness
• state of health, comfort, or distress (did your patient come in not looking well?)
• respiratory rate
• engagement (is your patient making eye contact? are they sensitive to certain parts of their body?)

These all related to determining health status, neurological behavior, and determining health goals. Following this, the steps and diagnostics performed on patients usually go from an order that is least to most invasive. The order follows (but depending on the type of assessment, some may be skipped, or certain aspects of one is focused on):

• General status (vital signs, blood pressure, heart rate) – These are all noted and assessed during the beginning period of the assessment. Blood, height, and weight are also taken.
• Head, ears, eyes, nose, throat – In a more controlled environment or unit, patient history is emphasized more to assess health (smoking history or respiratory diseases, for example). However, in an ER unit, checking for “ABCCS” (airway, breathing, circulation, consciousness, and safety) is the higher priority. This assessment is generally related to the respiratory and sometimes cardiovascular system.
• Neck – In the neck, you’ll primarily assess the musculoskeletal system, but you’ll also assess the lymph nodes.
• Respiratory – Again, in this local area, you are checking for “ABCCS.” This may sometimes be done in conjunction with an assessment of the heart.
• Cardiac – You are again monitoring heart rate when assessing the chest area. The cardiovascular and peripheral vascular system affects the entire body. In the interview of your patient questions of diet, nutrition, exercise, and stress levels may play a factor in the physical cues of this. If you are doing a focused assessment, collecting the patient’s and the patient’s family’s history of cardiovascular disease, asking about any signs and symptoms of cardiovascular and peripheral vascular disease, such as peripheral edema, shortness of breath (dyspnea), and irregular pulse rate, would be relevant.
• Abdomen – The abdomen is used to assess the gastrointestinal and genitourinary system, which is responsible for food ingestion, nutrient absorption, and waste elimination. A focused assessment may include collecting subjective data about the patient’s diet and exercise levels, or patient’s and the patient’s family’s history of the gastrointestinal and genitourinary disease, asking about any signs of abdominal discomfort or pain, nausea, vomiting, bloating, regularity, constipation, diarrhea, and characteristics of urine and feces.
• Pulses – Checking your patient’s pulse in different local areas around the body aids in assessment. This is sometimes done in conjunction with checking their extremities, like hands and feet. You are assessing musculoskeletal function, sensory function, circulation, and tissue perfusion.
• Extremities – In certain demographics of patients or if prompted, it might be necessary to check the range of motion and muscle strength of hands, feet, and joints. Checking for extremity reaction and sensitivity is also part of checking the neurological system. You may also be checking for gait and balance during a focused assessment.
• Skin – This is often done at the beginning of an assessment. For a more focused assessment, and sometimes of certain patients, you might check skin turgor, an indicator of fluid intake (or the lack of). This is done by pinching the skin gently. It should immediately snap back to position upon release without “tenting” (remaining pinched upright). Tenting indicates dehydration or fluid volume deficit. This is not an effective test of skin turgor on elderly patients. Lower skin elasticity means their skin often tents regardless of their fluid levels.
• Neurological – In a head-to-toe assessment, neurological clues may be taken throughout the rest of the body. The introductory period of the assessment lends a lot of clues to a neurological assessment of your patient. Noting non-verbal cues or behaviors is part of a patient’s mental assessment. Noting the speed at which someone is responding or comprehending is also part of the neurological assessment. Asking about injuries and checking for symptoms related to head injury (confusion, headache, vertigo, seizures, weakness, numbness, tingling, difficulty swallowing or speaking, and lack of coordination of body movements) can sometimes be assessed during other focused body assessments. This would also be where a family history of mental illness would be noted if any.

Record Keeping

Documentation is a critical part of the assessment process. If findings or abnormalities aren’t written down, you run the risk of forgetting to translate them towards a comprehensive care plan. In a professional setting, if you forget, you can write them the steps down on a checklist for you. Depending on the unit you are in, the amount of record-keeping goes up or down. For example, in an ICU, a nurse is running assessments much more often than for other units since monitoring of their vitals is so critical to their care.

Communicating Throughout

Communicate clearly throughout the assessment with your patient. Ask before you start touching the patient, explain what you are doing as you do it. These assessments may become routine to you, but are a one-off sometimes for patients. This helps to build rapport overall. In addition, ask patients about how they have been feeling. As professionals, we know a lot about identifying and solving issues, but they are the expert on their own bodies.

Do not underestimate the power of a thorough assessment. Taking the time and care shows, and can down the line, maybe be vital to a patient’s health. Accurate record-keeping can help with this as well on the physician’s end. Working on being efficient with your time comes with practice, so do not stress about remembering or doing everything as quickly as possible. It can also help better rapport between patients by using your due diligence to follow certain lines of questioning during head-to-toe assessments in order to get to the right focused assessments.

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More Resources for Head-to-Toe Nursing Assessment:

• Tips for Cardiac Nurse Assessment
• Neuro Nurse Assessment – Conscious Head to Toe
• Cardiac Assessment – What Nurses Need To Know
• Head to Toe Nursing Assessments from Nursing.com