How Does a Nurse Perform a Head-to-Toe Assessment?

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According to NursingLink, a nurse performs a head-to-toe assessment by evaluating the mental, physical and emotional aspects of a patient. Through a series of questions, observations and an examination, a nurse is able to evaluate all of these factors in a 10- to 20-minute meeting.

The first step to begin a head-to-toe assessment is to take the five vital signs, which include temperature, pulse, blood pressure, respiration and pain, according to NursingLink. The nurse asks how the patient feels and observes her non-verbal cues along with her verbal ones. The head, eyes, ears, mouth and throat are all assessed for functionality as are the level of consciousness and orientation of the patient during the examination.

The skin on the entire body is examined for its health, looking for abnormalities, such as moles, lesions, wounds and scars, as well as its moisture, color and temperature, according to NursingLink. The nurse listens to the lungs and heart from the front and the back of the chest and palpates the chest for tenderness or lumps. The nurse then listens to the bowel sounds, palpates the bowels and bladder for tenderness and asks the patient about her bowel movements. The nurse checks for any tenderness, lesions or sores on the genitalia. Finally, the extremities are examined for pulse, color and temperature. Once complete, the nurse asks the patient if she has any problems, concerns or questions. All of the findings are recorded at the end of the exam.