What Is a Head-to-Toe Assessment?


Quick Answer

A head-to-toe assessment is a process that nurses perform each time a new patient is encountered, according to Nursing Link. The nurse assesses the patient's physical, mental and emotional state, accounting for environmental and social issues that may affect the patient.

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Full Answer

Typically, a head-to-toe assessment begins with checking for five vital signs, according to Nursing Link. These signs are temperature, blood pressure, respiration, pain and pulse. Following this, the nurse then asks how the patient feels and requests that he observe the nearby environment, looking out for nonverbal cues to various possible issues.

Following the initial procedure, the nurse checks the patient's head, ears, eyes, nose, throat and mouth for signs of damage or indicators of disease, notes Nursing Link. The nurse then determines the patient's orientation and level of consciousness by asking questions and then examines the patient's skin, looking for scars, lesions, redness, irritation or wounds. Following this, the nurse tests the patient's lung and heart functionality, listens for bowel sounds in the patient's abdomen and assesses genitalia for lumps, tenderness or lesions.

The final physical step of a head-to-toe assessment is testing of the patient's extremities, according to Nursing Link. After this, the nurse asks the patient about any recent changes that may have occurred such as changes in sleep habits, appetite or bowel movement frequency.

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