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Head-to-Toe Assessment Nursing
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will explain how to conduct a nursing head-to-toe health

This assessment is similar to what you may be required to perform in nursing
care assessment
Head-to-Toe Nursing Assessment
The sequence for performing a head-to-toe assessment is:
 Inspection
 Palpation
 Percussion
 Auscultation
However, with the abdomen it is changed where auscultation is performed second
instead of last
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 In addition, ask the patient where they are, the current date, and current events
(who is the president and vice president) etc
 Collect vital signs: heart rate, blood pressure, temperature, oxygen saturation,
respiratory rate, pain level
NOTE: Before even assessing a body system, you are already collecting
important information about the patient
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)?
- Any noted abnormalities?
How is their emotion status (calm, agitated, stressed, crying, flat affect,
drowsy)?
Can they hear you well (or do you have to repeat questions a lot)?
- Normal posture?
- Abnormal smells?
- How is their hygiene?
Assess height and weight and calculate the patient’s BMI (body mass index)
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5 = Underweight
18
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9 = Normal weight
25
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9 = Overweight
30
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no drooping of the face on one side (eyes or
lips)
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Can they do this will ease?
Palpate the cranium and inspect the hair for infestations, hair loss, skin
breakdown or abnormalities:
Palpate for any masses or indentations
Skin breakdown (especially on the back of the head in immobile patients)?
Inspect the hair for any infestations: lice, alopecia areata (round abrupt balding
in patches), nevus on the scalp etc
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trigeminal nerve: This nerve is responsible for many
functions and mastication is one of them
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Palpate the frontal and maxillary sinuses for tenderness: patient will pressure
but should not feel pain

Eyes:
Inspect the eyes, eye lids, pupils, sclera, and conjunctiva
 Is there swelling of the eye lids?
 Is the sclera white and shiny?…not yellow as in jaundiceIs the
conjunctiva pink NOT red and swollen?
 Look for Strabismus and Aniscoria:
Strabismus: Do the eyes line up with another?
Aniscoria : Are the pupils equal in size…or is one pupil larger than the other? Are
the pupils clear…not cloudy?Normal pupil size should be 3 to 5 mm and equal
Test cranial nerves III ( oculomotor ), IV (trochlear), VI
( abducens )
 Have the patient follow your pen light by moving it 12-14 inches from
the patient’s face in the six cardinal fields of gaze (start in the midline)
 Watch for any nystagmus (involuntary movements of the eye)
Accommodation ?
 Make the lights normal and have patient look at a distant object to dilate
pupils, and then have patient stare at pen light and slowly move it closer
to the patient’s nose
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 Palpate the mastoid process for swelling or tenderness
TOPHI
Tests cranial nerve 8 VIII…vestibule cochlear nerve:
Tests cranial nerve 8 VIII…vestibule cochlear nerve:

Test the hearing by occluding one ear and whispering two words and have the
patient repeat them back
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It should appear as a
pearly gray, translucent color and be shiny
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Also, the cone of light should be at the 5:00 position in the right ear and 7:00
position in the left ear
TYMPAMIC MEMBRANE

Nose:
Inspect nose
 Symmetrical (midline, look at septum for any deviation)
 Drainage (ask patient if they are having any discharge)
 Use a penlight to shine inside the nose and look for any lesions, redness,
or polyps
 Then have the patient close one nostril and have the patient breathe out of
it and do the same for the other…are they patent?

Test cranial nerve I
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The teeth
should be white and free from cavities
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Inspect tongue:
- Should be moist and pink (NOT dry or cracked or beefy red (pernicious
anemia) Underneath the tongue should be no lesions or sores
- Inspect hard and soft palate and tonsils (no exudate on tonsils) and uvula
should be midline

Test cranial nerve XII…
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hypoglossal:
 have patient stick tongue out and move it side to side
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Neck:
Neck:
Inspect the trachea
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Palpate thyroid gland from the back: note for nodules, tenderness or
enlargement…normally can’t palpate it
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2+ is
normal)
Auscultate for bruits at the carotid artery with BELL of stethoscope (listen for
a swooshing sound which is a bruit)…have patient breathe in and out and hold
it while listening

Upper extremities:
Inspect arms and hands

 Deformities? ( Heberden or Bouchard nodes as in osteoarthritis on
fingers
...
)
 Hand and fingernails for color: they should be pink and capillary refill
should be less than 2 seconds
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If the patient receives dialysis and
has an AV fistula, confirm it has a thrill present
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Chest:
Chest:
Inspect the chest
 Is the respiratory effort easy? Is the patient using the abdominal or
accessory muscles for breathing?
 Does the patient have a barreled chest (some patients with COPD do)?
 Assess the skin for wounds, pacemaker present, subcutaneous port etc
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Pulmonic: found left of the sternal border in the 2nd intercostal space
REPRESENTS S2 “dub” which is the loudest
Erb’s Point: found left of the sternal border in the 3rd intercostal space…no
valve here just the halfway point
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Mitral: found midclavicular in the 5th intercostal space REPRESENTS S1 “lub”
(also the site of point of maximal impulse) APICAL PULSE…
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Then listen with the BELL of the stethoscope at the same locations: for a
blowing or swooshing noise…heart murmur
Lung Sounds:
Lung Sounds:
If you would like to hear some abnormal lung sounds, please watch our video
called “abnormal lung sounds”
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 Lastly move to the mid-axillary are at the 6th intercostal space and you
will be assessing the right and left lower lobes
Auscultate posteriorly:
 Start right above the scapulae to listen to the apex of the lungs
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This will assess the right and left
upper lobes
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 Have patient lay supine
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If a female patient, ask when their last
menstrual period was
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 Characteristics of the navel (invert or everted )
 Masses (check for hernia after auscultation), ?
Auscultate with the diaphragm for bowel sounds:
Auscultate with the diaphragm for bowel sounds:
 Start in the RIGHT LOWER QUADRANT and go clockwise in all the
4 quadrants
 Should hear 5 to 30 sounds per minute…if no, bowel sounds are noted
listen for 5 full minutes
 Documents as: normal, hyperactive, or hypoactive
Auscultate for bruits (vascular sounds)





At the following locations using the BELL of the stethoscope:
Aorta: slightly below the xiphoid process midline with the umbilicus
Renal Arteries: go slightly down to the right and left at the aortic site
Iliac arteries: go few a inches down from the belly button at the right and
left sides to listen
 Femoral arteries: found in the right and left groin
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They don’t
have good sensation on their feet
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)
 Is there any breakdown on the heels?
 Assess joints of the toes and knees (any crepitus, redness, swelling, pain
Palpate pulses bilaterally: popliteal (behind the knee), dorsalis pedis (top of
foot), posterior tibial (at the ankle) and grade them
Palpate muscle strength: have patient push against resistance with feet and lift
legs
Test Babinski reflex: curling toes is a negative normal response
Turn patient over and look at back (could listen to lung sounds if haven’t
already) look for skin breakdown on back and bottom and abnormal moles



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