Patient assessment is one of the most important skills you must learn and master as a nursing student. You must be able to evaluate any patient to discover all their current and potential problems and needs. When you master patient assessment, you will be able to do your job correctly in the future and you will get a lot of job satisfaction from that.
In this post, we will reveal to you everything you need to know about performing a comprehensive patient assessment. We will particularly focus on how to conduct a comprehensive head-to-toe patient assessment and write attendant reports. It is a skill necessary during admission, beginning of every shift, and as deemed necessary depending on the hemodynamic status of the patient and context.
What is a head-to-toe assessment?
A head-to-toe assessment is a thorough or exhaustive evaluation of a patient’s health status of all major body systems to determine all their needs and problems from their head to their toes.
It is a comprehensive physical examination that enables healthcare practitioners to understand and act on the needs and problems that a patient present with in the healthcare setting.
Normally, head-to-toe assessments are done by registered nurses (RNs). However, they can also be done by physician assistants, physicians, and paramedics.
Not every single patient needs a head-to-toe assessment. Patients that come with specific complaints or issues typically do not need a full body examination. It is only patients that visit healthcare facilities for their annual physical examination that need a full-body head-to-toe assessment. Those presenting to a healthcare facility with a specific complaint or health problem will be assessed through a problem-focused assessment that focuses on specific care goals, which is the opposite of a head-to-toe assessment.
Patients that are too sick to speak may also need a head-to-toe assessment.
A brilliantly written head-to-toe assessment report will make it easy to comprehend the problems and needs of the subject (the patient).
The assessment employs certain methods of examination including inspection, palpation, auscultation, and percussion as we shall see in the subsequent sections of this guide.
What You Need to Know About Head-To-Toe Assessments
- The assessments are comprehensive. Typical health assessments in hospitals and other healthcare centers are usually problem-focused. They are problem-focused in the sense that the person conducting them will mainly focus on the part/area of the body that has an issue or a problem. In contrast, head-to-toe assessments are comprehensive and they cover the entire body from the top to the bottom. They often include an examination of health history too.
- The assessments are done by experienced nurses. To ensure professionalism, head-to-toe assessments are often strictly done by experienced nurses (usually registered nurses or nurse practitioners). However, this does not mean they cannot be done by other healthcare workers such as physician assistants and paramedics. It simply means these other healthcare workers don’t do them as frequently as experienced nurses.
- The assessments usually take less than half an hour. While head-to-toe assessments are comprehensive, they usually don’t take more than half an hour. How long an assessment will take will be determined by the health status of the client/patient. An assessment for a patient with a limited health history will take less time than one for a patient with low health status and a bigger health history.
- The assessments must observe standard precautions. No matter how clean or healthy a patient looks, standard precautions must be observed during an assessment to protect both the patient and the nurse. The precautions entail wearing gloves and other PPEs, hand hygiene, and the safe handling of surfaces and equipment.
- The assessments require a host of equipment. To conduct a comprehensive full body health assessment, you will need the following basic equipment: stethoscope, penlight, tape measure, height measurement device, scale, watch, blood pressure instrument, thermometer, and gloves. Additional equipment for an even more thorough assessment includes an alcohol swab, tongue depressor, reflex hammer, ophthalmoscope, and otoscope.
- Assessments reports are usually done on a form. In most hospitals and health facilities, health assessment reports are usually done on health assessment forms already prepared by the organization. This means that all you need to do to write a health assessment report in an actual clinical setting is to write your observations in the provided form. No need to come up with your own reporting format and make your unique report.
- Assessments require trust and respect for work. Head-to-toe assessments are thorough comprehensive and in-your-face. Therefore, there is a need for the nurse to establish a working relationship based on trust and respect for their work. Showing the patient respect and regularly asking them how they are doing during assessment can help to minimize any jitters and negative feelings.
- Assessments usually begin with the same basic steps. Comprehensive assessments usually commence with the same basic steps. The first step is usually hand hygiene followed by wearing gloves. This is usually followed by introducing oneself to the patient, confirming the patient’s identity, and assessing the ABCs before the real deal.
- Noticing the abnormal is important. Noticing the abnormal and the irregular is the most important thing during comprehensive assessments. It is crucial to try to notice and note down the abnormal during your comprehensive assessment. This is the only thing that will ensure the patient’s current and future needs and problems are given the attention they need.
- Noticing and noting down nonverbal cues is also important. Patients only say that which they know about themselves. As a nurse, it is up to you to notice the extra things about the patient; the things they may not know about themselves. It is up to you to notice what the patient is doing normally and what they are not doing and to note it all down to ensure that your report is as comprehensive and as helpful as it can be.
Head-To-Toe Assessment Guide and Report
Follow the steps below to conduct a head-to-toe assessment and write a report.
1. Establish a Therapeutic Relationship
The first step before you begin the assessment is to establish a therapeutic relationship with the client. Creating a rapport with the patient helps them ease up and share their feelings without boundaries. You can do this by:
- Introducing yourself
- Explaining your role
- Explaining to the patient what you will be doing
- Asking the patient what brings them to the facility
- Addressing any questions that the patient might have before you commence
- Asking if there is anything you can do to make the patient comfortable
Your discussion with the patient should be based on your initial impression once you get into the room. You can begin making mental notes once you walk into the room by taking note of the physical cues such as abnormal smells, slurred speech, alertness of the patient, signs of distress, painful sounds, and general appearance of the patient.
2. Get an Assessment Report Form
Probably the most important thing to do when you are conducting a head-to-toe assessment is documentation. You must document everything you evaluate during the patient assessment. Failure to do this will make it very difficult for you to remember the current or future needs and problems of the patient. This will, in turn, make it difficult for you to create an accurate and effective care plan for the patient. To make it easier to conduct the assessment, you should have a checklist or a map of all the things that you need to examine and the report should have everything you need.
So, make sure you start your head-to-toe assessment by getting an assessment report form. Make sure the form is for a comprehensive assessment to ensure you capture everything you view or assess during the patient examination exercise. There are many assessment forms available online.
3. Assess Vital Signs and Neurological Indicators
You can start a head-to-toe assessment from any part of the body since you will cover the entire body anyway. However, it is best to start by assessing the vital signs first. This will sort of ease the patient into the comprehensive assessment process.
The following are the most important things to do when assessing vital signs and neurological indicators:
- Check orientation: Check if the client is alert and okay. Do this by asking for their name, the day, and the time. If the client is responsive, note it down.
- Measure temperature: Temperature is one of the most important vital signs. Measure and record the patient’s temperature. Also record where the temperature was taken armpit, forehead, ear, rectally, or orally. These different methods do not have the same accuracy level hence why you must not the method you used.
- Assess blood pressure: Just like temperature, blood pressure is also an important vital sign. You should assess blood pressure manually or use an automatic blood pressure machine. Record blood pressure accurately after assessing it. Make sure you understand how to measure pressure manually.
- Measure heart rate. Heart rate is how fast the heart is beating per minute. You need to measure the heart rate of the patient. You can measure heart rate in the neck (carotid pulse) or on the wrist (radial pulse) by placing two fingers on the area and counting the beats for 60 seconds (one minute). Normal heart rate is between 60 to 100 beats per minute. If you notice anything irregular with the patient’s heart rate, note it down next to the heart rate in the report form.
- Measure respiratory rate. Respiratory rate is a measure of how fast one is breathing. It is important to measure the respiratory rate of your patient. Do not tell the patient that you want to measure their respiratory rate as this will most likely lead to them changing their breath rate. So secretly count the number of breaths they take for 30 seconds and multiply the number by two. This calculation will give you a respiratory rate per minute. Normal respiratory rate is between 12 to 20 breaths per minute. If you notice anything abnormal about the patient’s respiratory rate, note it next to their respiratory rate.
- Measure the patient’s height and weight. It is crucial to capture the patient’s height and weight when taking their vital signs. Record these accurately in your assessment report form.
4. Examine The Patient’s Head
After taking the patient’s vital signs, you should proceed to examine their head. Check the condition of the head and the face and note down everything, especially the things that are abnormal or out of place.
- Examine the hair. Look at the hair and its distribution. Is the hair okay? Is it evenly distributed? It is brittle? Note down everything important and especially the things that stand out about the patient’s hair.
- Examine the health of the scalp. Does the scalp look healthy? Does it have dandruff or dryness? Check for scabs, sores, and bumps on the scalp. Record everything you see especially the things that strike you as abnormal or irregular.
- Examine the skull for soreness. Touch every part of the skull to ensure you identify any sore or tender areas.
- Examine the face for symmetry. Is the patient’s face symmetrical? Is there anything odd about the way they smile, raise eyebrows, or frown? Of course, you will have to make them do all these things to make your observations.
- Assess the state of the cranial nerve V
5. Assess The Eyes
The eyes may look simple but a lot of time is spent assessing them because they are complicated organs. When conducting a head-to-toe assessment of your patient, you will need to assess the eyes to check if they have healthy vision. You will also need to check the health of eye tissues including the cornea, sclera, and conjunctiva.
- Check for symmetry. Are the eyes symmetrical? Are the palpebral fissures equal? If the eyes are equal note this down in your report form. Do the same if they are not equal.
- Check for eyelash and eyebrow distribution. Are the patient’s eyelashes and eyebrows evenly distributed? Are they symmetrical? Record your observations.
- Examine the cornea. Examine the patient’s left cornea by shining a penlight from the side to illuminate it. Do the same for the right cornea. An illuminated cornea should be clear and smooth. Is this what you see? Note your observations.
- Examine the sclera. Open the patient’s eyelids and examine the white of the eye. Are they white? Are they yellow? Note down the color you observe. Note any lesions you also observe. Excess capillaries should also be noted.
- Examine the conjunctiva. When examining the sclera, take advantage of the open eyelids to check the conjunctiva. The conjunctiva is normally pinkish and without lesions. If you notice any abnormality, record it in your assessment report form. If it is unusually pale or red, you should also record this in your form. A pale conjunctiva can indicate anemia, while a red one can indicate infection or inflammation.
- Check vision using the Snellen chart. Ask the patient to stand at least 20 feet away and assess their vision using the Snellen chart. Assess the vision of both eyes. Once you are done assessing their vision, interpret the results and put the interpretation and conclusions in your assessment form.
- Check six cardinal positions of the gaze. Switch on a penlight and ask the patient to follow its movement. Move the penlight to the positions of gaze to check if the patient’s eyes follow correctly. If there is a problem, note it down.
6. Assess The Ears
The ears are very important body organs. You must assess them when doing a head-to-toe assessment. The following are the most important things you must do when examining a patient’s ears.
- Examine the auricle. You have to examine the auricle for damage. Check if the skin is intact and touch it (palpitate) to identify tenderness and lesions. Also, check to ensure the auricles are symmetrical. Note down everything in your report, particularly those that are not normal.
- Examine the inner ear. After examining the auricle proceed to look inside the ear. Pull the auricle back and up to get a good view of the ear canal and the hearing membrane. Write down what you see. If anything doesn’t look right, make a special note of it.
- Assess hearing capacity. This is normally done using the Whisper Test. Stand 2 feet behind the patient and whisper a word to them and ask them to repeat it to you. Do this for one ear and then the opposite one. If normal, write it in your report form. If not normal, also write it in your report and clarify what is not normal.
- Check for hearing loss. Use the Weber test or Rinne test to check for hearing loss. The Weber test is simpler. It involves striking a special fork and placing it on the forehead (at the center). In case the sound coming from the fork is stronger in one ear, it indicates possible hearing loss in the other ear.
7. Assess The Nose
A head-to-toe health assessment cannot be considered complete without an examination of the nose. You need to check the nose both internally and externally.
- Check nose symmetry and tenderness. Look at the nose carefully. Is it symmetrical? If yes, note this down. Are the nostrils relaxed? If not, it could be a sign of respiratory distress. Make a special note of this in your report. Also, palpate the patient’s nose for tenderness. If there is tenderness anywhere, put this observation in your report.
- Assess the nostrils. Shine your penlight into each nostril and look carefully at the membranes. They should be pink without any lesions. Record the ordinary and also anything out of the ordinary in your report.
- Examine the septum. Utilize your penlight to make clear the septum and ensure it is not damaged in any way. If it is, make note of it. If it is not, describe its normal condition.
- Check each nasal passage for blockage. As the patient blocks one nostril and breathes to the other and then repeats the same thing with the opposite nostril. If the patient cannot breathe with one nostril, there is a strong chance it is blocked.
- Assess the patient’s sense of smell. Ask the patient to close his eyes and ask him to identify the scent of any scented thing you might find in the examining room (e.g. rubbing alcohol, coffee, and so on). Of course, you’ve got to hold these things close to his nose to give him a proper chance to smell them.
8. Examine The Mouth and Throat
Your report must include an assessment of the mouth and the throat. The mouth must be examined both internally and externally.
- Check the lips. What color lips does the patient have? Are they moist, dry, or chapped? Note down everything. What shape are the lips? Are they symmetrical? And are they healthy or do they have lesions? Write down your observations in your report.
- Check the gums and teeth. Check the gums for retraction, puffiness, bleeding, or any abnormal appearance. Record what you see. Then check the teeth. Count them and look at the color and alignment. Is everything perfect? If yes, write that down. If not, note exactly what is not perfect.
- Assess the tongue. The tongue is normally center position, pink, and without any sores/lesions. Check your patient’s tongue to ensure this is the case. If it is not, specify in your report whatever issue or problem you’ve noted. It should also not be smelly. A smelly tongue is a sign of disease especially if the tongue is physically clean.
- Examine the uvula, the palate, and the buccal mucosa. The uvula should be center-positioned, pink, and without any swelling. Similarly, the mouth membranes should be moist, pink, and without any swelling or lesions. Note down the condition of these mouth parts in your report form.
- Look at the tonsils. Gently push the tongue down to look at the tonsils. Do you notice tonsil stones, redness, swelling, infection, or inflammation? If yes, there could be a problem. Record your observations.
- Look at the jaw joint. Palpate the jaw joint with the patient’s mouth open and then repeat with the mouth closed. There should be no pain in both instances.
9. Assess The Neck and The Shoulders
When assessing the neck and the shoulders, you will need to focus on musculoskeletal function. You will also need to look at the lymph nodes.
- Range of motion. The first thing you will need to assess is the neck’s range of motion. The patient should be able to look left, right, up, and down freely and without experiencing any pain.
- Shoulder movement. Check to see if the patient’s shoulders move freely. Ask them to shrug their shoulders. The shrug ought to be symmetrical and without any pain.
- Palpate neck and shoulder nodes. Palpate face, neck, and underarms lymph nodes for pain and tenderness. If you notice any squirming repeat and ask if there is pain. Note down what you find out.
- Palpate neck and trachea. Palpate around the neck and feel for tenderness, especially on the trachea and thyroid.
- Look for JVD. JVD stands for Jugular Venous Distension. This is a bulging vein in the side of the neck. It is a big sign that one has heart disease. The patient needs to lie down on a 45-degree angle bed for you to see the vein. Note down if the patient has it.
10. Examine The Chest Area
In the chest area, you need to examine the thorax and the lungs.
- Palpate the thorax region. Palpate the thorax region for asymmetry, lumps, tenderness, and lesions.
- Use a stethoscope to listen to lung sounds. Listen to lung sounds both front and back. Note down any irregular sounds.
- Examine respiratory expansion. Check if your patient’s lungs expand and contract normally. You can do this by placing your hands on their mid-back and asking them to inhale as much as they can.
- Ask the patient if they have any respiratory problems. Talk to the patient and ask them if they have any respiratory issues. Note all the issues they share with you.
11. Assess The Circulatory System
In this step, you will examine the heart and if it is working as expected.
- Examine heart valves. Use your stethoscope to listen to your heart’s mitral valve, tricuspid valve, pulmonic valve, and aortic valve. Try to identify irregular sounds. If there is anything irregular make note of it.
- Check temporal and carotid pulses. Check temporal and carotid pulses bilaterally to ensure pulses are regular. Note down your findings.
12. Examine The GIT System
After assessing the heart, you should assess the GIT system.
- Ask about bowel movements. Ask the patient if they experience regular bowel movements. Also, ask them about their appetite and urination. Note down all responses.
- Check the abdomen. Investigate the patient’s abdomen for concavity, distension, lesions, and lumps.
- Palpate and listen to four quadrants of the abdomen. Palpate them for tenderness and lumps, and then listen to them for bowel sounds. Write down your findings.
13. Assess The Hands and Arms
At this stage, you should assess the hands and arms of the patient as follows.
- Check fingernails. Use the Cap Refill Test to check the patient’s fingers. This test involves pinching a finger and releasing it to note if the color returns faster than 3 seconds. If the color doesn’t return, there is a problem.
- Examine skin turgor. Pinch the skin on the back of your patient’s hand and then release it. Does its tent? If it does, this is a sign that your patient is suffering from dehydration.
- Assess pulses in the arms. Check both brachial and radial pulses. Write down if they are regular or irregular.
- Assess dull and sharp sensations. Tell your patient you are going to prick them lightly and ask them to close their eyes. Use a sterile pin and a cotton ball to prick and touch them randomly on both arms. Can they identify the right sensation every time? Note down what you observe.
- Examine the range of motion. Check if your patient has a full range of motion in the wrist, elbow, and shoulder areas. Note down any problems you find in your report form.
14. Assess The Feet and Legs
This is the second last thing you need to do in head-to-toe assessment.
- Check toenails. Use the Cap Refill Test to examine any of the patient’s toenails. The test involves pinching a toenail and releasing it to check if its pre-pinching color returns faster than 3 seconds. If the color doesn’t return, there is a problem.
- Examine gait. As the patient walks around the examining room for any other test (e.g. Snellen test), examine their gait. It should be balanced and regular. Record your findings.
- Assess pulses in the legs. Check the ankle, top-of-the-foot, behind the knee, and femoral pulses. Write down if they are regular or irregular.
- Assess dull and sharp sensations. Tell your patient you are going to prick them lightly and ask them to close their eyes. Use a sterile pin and a cotton ball to prick and touch them randomly on both legs. Can they identify the right sensation every time? Note down what you observe.
- Examine the range of motion. Check if your patient has a full range of motion in the ankles, knee, and pelvis areas. Note down any problems you find in your report form.
15. Check If Your Report Form Is Accurate
The step above is the last stage of head-to-toe assessment. The only thing you need to do is to do now to complete the assessment is to check if your report is accurate.
You should do this the moment you are done with the step above. This is because everything is still fresh in your mind. Make sure the report is filled and that every piece of information you entered is correct and makes sense.
Proofread and ensure that there are no mistakes that could mislead you or anybody else reading the assessment report form.
Final Words of Head-to-Toe Assessment
You now know how to do a head-to-toe assessment. You also know that all you need to do to write a head-to-assessment report is to fill in an assessment report form during your assessment.
Since filling in assessment reports is often quite a challenging task, many nursing learners dread doing it. Luckily for them, we exist. We are a nursing assignment help company and assistsistance with completing any type of nursing assignment or task.
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