A head-to-toe assessment is a physical examination or health assessment, and it is one of the many important components of understanding a patient’s needs and problems. This assessment is performed during every shift and sometimes multiple times to determine if there have been any changes in your patient’s status.
We've put together a step-by-step guide to what happens in a nursing head-to-toe assessment and how nurses should understand the physical, emotional, and mental aspects of someone’s body systems.
Head-to-Toe Assessment Experts
We interviewed two healthcare experts to learn their best practices for conducting head-to-toe assessments.
Terri Zucchero, PhD, RN, FNP-BC, is a nurse practitioner in Boston, and Angela Haynes Ferere, DNP, FNP-BC, MPH, serves as the DABSN Program Director at Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.
A head-to-toe assessment is an evaluation of all the body's systems to give you a picture of the patient's health needs and problems. “This baseline examination determines knowledge about patient health needs, current health status and patient goals for personal health outcomes, including health promotion and wellness counseling,” Zucchero says.
There are several types of assessments that can be performed:
1. Complete Health Assessment
A complete health assessment is a detailed examination that typically includes a thorough health history and a comprehensive head-to-toe physical exam. This type of assessment may be performed by registered nurses for patients admitted to the hospital or in community-based settings such as initial home visits.
Advanced practice registered nurses (APRN) such as
nurse practitioners (NP) also perform complete assessments when doing annual physical examinations.
2. Problem-Focused Assessment
A problem-focused assessment is an assessment based on certain care goals. For example, a nurse working in the ICU and a nurse that does maternal-child home visits have different patient populations and nursing care goals, she says. These assessments are generally focused on a specific body system such as respiratory or cardiac. While the entire body is important there is usually not enough time for a detailed full-body assessment.
Step 1: Establish Trust
When beginning an assessment, Zucchero says, “Establishing a personal relationship of trust and respect between the patient and the nurse is vital.” She adds that it is important throughout an assessment to assess how the patient is doing, and make sure they are properly draped and comfortable. You'll want to introduce yourself to the patient and explain the assessment process
Step 2: Confirm the patient’s ID
Step 3: Note The patient's Appearance and Status
“During an assessment, the first thing that should be noted is the patient’s overall appearance or general status,” Zucchero says. “This includes level of alertness, state of health/comfort/distress, and respiratory rate. This is done even prior to taking vital signs.”
Step 4: Assess the ABCs
Prior to starting a detailed assessment, you'll want to assess the ABCs - airway, breathing, and circulation.
Usually, the assessment begins with the least invasive to most invasive, allowing time for the patient to become more comfortable with the examiner. It also increases the likelihood that the examiner will not forget a system during the exam.
Step 5: Look for Abnormalities
Differentiating normal from abnormal is an important skill, Zucchero explains.
Some examples of major abnormal findings are changes in normal respiratory rate that indicates respiratory distress, or a change in skin color such as pallor that may indicate anemia or jaundice that typically indicates liver problems.
Generally, the human body is bilaterally symmetrical. When you are examining a patient, make note of any unusual asymmetry. If a patient is weaker on one side than another, or has a limited range of motion, or one side seems limper or otherwise different from the other side, there could be an underlying neurological or musculoskeletal issue.
