Every nurse does their head-to-toe assessment a bit differently and as a new grad it might be difficult to pick up the most important parts for each patient. Doing a focused assessment that is patient specific is super important and will be a real time saver. Especially when you’re on your own taking care of five patients at a time.
For example, if a patient has a sacral wound or maybe scabies, his/her assessment is going to be more skin/wound related than a 25-year-old fully ambulatory patient here for appendicitis with no prior skin breakdown. The following is a general guideline on how a typical head-to-toe assessment should go. But keep in mind this is going to vary patient to patient, and also unit to unit.
Introduce Yourself & Implement Your Start of Shift Plan
See post on Start of Shift Plan for New Nurses. Address pain, get report, complete your med pass, etc.
By introducing yourself and having a simple conversation you can easily tell if the patient is oriented from the start of your assessment. If you are unsure or if the patient has a history of disorientation, then go ahead and ask more specific person, time, and place questions. If you have a patient with neurological concerns, be sure to complete a full neurological assessment.
Also visit Essentials of a Good Bedside Handoff Report, Nursing Fundamentals: A Guide to Pain and A Guide to the 10 Rights of Medication Administration for more info.
Pro Tip: Be sure to check precautions for each patient before entering the room. If they are on contact, droplet, or airborne precautions, there should be a PPE box in front of their room. Make sure to don all PPE before entering your patients’ room. See How To Don and Doff PPE for Medical Professionals and Nursing Fundamentals: A Guide to Infection Control for more info.
Do a Quick Once Over
While introducing yourself and making small talk, you’re also building rapport. This should always be done before touching any patient of any age for a head-to-toe assessment.
While you’re making conversation, you should also be looking at their IV site/sites, Foley, and any other lines or drains. Make sure the IV pump is running the right fluid at the right rate. If there are any IV medications, make sure they are also being ran appropriately.
Also observe if the patient is sitting up or laying down and if they are moving all extremities while talking to you.
Use Your Stethoscope
Once you have built rapport with your patient, go ahead and take out your stethoscope. Ask the patient if you can listen to their heart, lungs and abdomen as part of their head-to-toe assessment.
This is a good transitional step because you still are not directly touching the patient. Your stethoscope is what’s making the contact for you so by the time you ask to touch the IV site or to look at their back or wounds, you will have worked your way up to it.
Some patients don’t mind being touched at all while others are a bit more reserved, making this technique appropriate for everyone.
Visit Nursing Bag Essentials for New Nurses to see more important nursing tools.
Arms
Now that you have talked to your patient, assessed their orientation, listened to their heart, lungs, and abdomen you can move on to the skin. Be sure to inform the patient of everything you’re doing ahead of time. This will make your patient more comfortable.
IV
Look over each arm, are there any IV’s? If so, ask if there is any pain or tenderness that isn’t expected. Make sure the IV isn’t infiltrated and take this time to educate your patient on what a bad IV would look like.
Let the patient know that if the IV becomes painful, if the pump starts beeping, or if it starts to sting or become red and swollen to let you know. As these are all signs that the IV is no longer any good.
While you are educating the patient on their IV, you should also flush the site to make sure it is still patent. Also note if there is any blood return.
Visit Nursing Fundamentals: A Guide to IV Therapy and A Guide to Intravenous Fluids for more information on IV’s.
Skin
In addition to looking at any IV sites, you should look at the skin on both arms. Is there any skin breakdown, discoloration, redness, or rash?
Visit Nursing Fundamentals: A Guide to Wounds for more info.
Circulation/Pulses
While you’re here, also assess the circulation and pulses in each arm.
Mobility
When looking at the skin and assessing the pulses, is the patient able to move each arm? Is there some sort of impaired mobility or weakness? Is this acute or chronic?
Legs
Skin
Now onto the legs. Similarly, you are going to want to check the skin. Are there any scabs? Are the legs dusky in color? Which brings us to circulation.
Circulation/Pulses
Do the patients’ toes look purple? Are they getting good circulation? Are they cold to the touch? Clammy?
Mobility
While doing your leg assessment, is the patient able to move their legs around? Is there some sort of impaired mobility or weakness? Is this acute or chronic?
Feet & Heels
Skin
When patients are in the hospital, they are (for the most part) laying down. And because heels are bony prominences, skin breakdown is something you really have to watch for. So be sure to remove the patients socks and get a good look at the color of the skin on the heals in every head-to-toe assessment. If there is any redness, is it blanchable? Do they already have some kind of skin barrier? Or do you need to apply one?
Visit Nursing Fundamentals: A Guide to Pressure Ulcers for more information.
Circulation/Pulses
Now that you have the patients sock off, make sure to check the pulses. Are they equal? Bounding? Not palpable?
Go ahead and put the patients socks back on put their blankets back as well.
Privates
If the patient has a Foley, skin breakdown, or any sort of infection of the private parts, then you are going to need to assess these areas too. Again, be sure to explain exactly what you are doing before you do it.
If there’s a Foley, then make sure it is properly secured to the leg. Check the skin around the Foley as well as under the stat-lock. Is the skin intact? Is it irritated? Does the stat-lock need to be replaced or does the site need to be changed? Also assess the output and note the color of the urine. Is it clear or cloudy? Pink or yellow?
Torso
You can now put the blanket back and ask to see the patients torso. You might have already been able to visualize this area when you listened to their lungs, if so great, you can move onto the back. If not, then now’s your time.
Skin
Assess the skin. Is petechiae present? Are there any scars or rashes present?
Devices
Does the patient have anything attached to them? An insulin pump? Ostomy pouch? Urostomy bag? If so, note the skin around the devices and be sure to ask the patient if they need any supplies or assistance in changing/cleaning the device.
Back
On to the back! Ask the patient to either sit up or turn to the side so you can assess their back.
Skin
Look at the coloring of the patient skin. Is there any scarring? Or discoloration?
Devices
Are there any devices such as nephrostomy tubes? If so, note the skin around the devices. Again ask the patient if they need any supplies or assistance in changing/cleaning the device.
Sacrum
Just like the heels, the sacrum is another bony prominence where the skin can easily breakdown. Especially in the hospital setting with total care patients or patient with paralysis. Be sure to remove any diapers or skin barriers that might be in the way to get a good view of the sacrum. Note if the color of the skin on the sacrum consistent with the rest of the body? Is the skin intact? Are there any signs of skin breakdown?
You’re Done!
Pro Tip: If you are doing a head-to-toe assessment on a total care patient, do everything you can without having to move the patient. Then coordinate with your CNA to go into the patients’ room together to help finish your assessment.
Additionally, you’re going to want to remember that you have all shift to get your assessments done! There isn’t a strict order to follow where you must complete your assessments all before med pass for example. You have the entire shift. And if you forget something and don’t realize until you start charting, your patient is still going to be there to assess later on if need be. Keep in mind too that your patients (for the most part) are aware of what’s going on with them, so if you have a question, just ask them!
If you find yourself getting nervous before your shift, visit How to Overcome Pre-Shift Anxiety for Nurses.
Have more Head-to-Toe Assessment tips? Comment below!
Like this post? Check out the following for more nursing tips!
- How to Organize Your 12-Hour Nursing Shift
- 16 Things You Need to Bring to Clinical
- Medical Abbreviations You Must Know
- How to Handle Aggressive Patients
- Imposter Syndrome as a New Nurse
- What to Expect in the First Year as a New Grad Nurse