Head-to-Toe Assessment: Complete 12-Step Checklist

Need some info on conducting a head-to-toe assessment? Whether you are just looking for a quick head-to-toe assessment cheat sheet or a total guide to conducting a nursing head-to-toe assessment in a clinical setting, we’ve got you covered! We’ll start with a brief overview of the assessment process, then a quick head-to-toe assessment checklist. After that, we’ll do a deep dive on all the assessment steps, and wrap up with some example videos.    

What Is a Head-to-Toe Assessment?

A head-to-toe nursing assessment is a comprehensive process that reviews the health of all major body systems (from “head-to-toe,” hence the name). head-to-toe assessments are usually performed by nurses as part of a physical exam, although physician assistants, EMTs, and doctors also sometimes perform head-to-toe assessments. Nurses and other clinicians may not perform a head-to-toe physical assessment for every single patient, depending on the setting they work in. They are typically a key part of primary care visits and annual physicals, but less common when the patient presents with a specific complaint or issue.  

Quick Head-to-Toe Assessment Checklist

In case you’re just looking for a head-to-toe assessment cheat sheet, we’ve created a brief list here of the major things to check for. You can click on each of the body systems to be taken to a more in-depth description with instructions for that part of the head-to-toe assessment. Or maybe you’re looking for a nursing head-to-toe assessment form that you can print out and write on? We have that, too! Just click on this link for a PDF:

• Head-to-Toe Assessment Checklist

Note that different health systems (or professors, if you’re a nursing student!) may have slightly different expectations for all of the specific tests you will perform as part of the head-to-toe assessment. While the below nursing head-to-toe assessment cheat sheet can function as a guide, be sure to comply with the specifications of your place of work or school. Also note that assessments for different sub-populations (like a pediatric head-to-toe assessment) may have different procedures. This is a general adult nursing head-to-toe assessment guide.   So this is not a guide to head-to-toe assessment for cats and dogs.  

Assessment Tools

• Penlight
• BP cuff
• Thermometer
• Tongue depressor
• Stethoscope
• Sterile sharp object (like toothpick or pin)
• Sterile soft object (like cotton ball)
• Something for patient to smell (could be an alcohol swab)

 

Vital Signs, Stats, and Neurological Indicators

1. Oriented x 3
2. Assess temperature
3. Measure blood pressure
4. Assess heart rate
5. Assess respiratory rate
6. Height and weight

 

Head/Face

1. Check distribution and condition of hair
2. Check scalp for bumps, nits, lesions, etc
3. Palpate skull for tenderness
4. Check for symmetrical facial movements
5. Assess sharp and dull sensation on face

 

Eyes

1. Assess symmetry
2. Eyebrow and eyelash distribution
3. Check state of conjunctiva
4. Check sclera
5. Assess state of patient’s cornea
6. PERRLA
7. Check the six cardinal positions of the gaze
8. Assess patient vision with Snellen Charts

 

Ears

1. Inspect and palpate auricle for lesions, tenderness
2. Look inside ear; assess ear discharge and tympanic membrane
3. Tuning fork tests (Weber’s Test, Rinne Test)
4. Assess patient hearing with whisper test

 

Nose

1. Palpate nose and assess symmetry
2. Check septum
3. Check inside nostrils
4. Verify that patient can breathe through each nostril
5. Verify patient sense of smell is intact
6. Palpate sinuses

 

Mouth and Throat

1. Moistness and color of lips
2. Inspect teeth and gums
3. Assess buccal mucosa and palate
4. Examine tongue
5. Look at uvula
6. Look at tonsils
7. Palpate jaw joint

 

Neck and Shoulders

1. Check neck range of motion
2. Check shoulder shrug with resistance
3. Palpate lymph nodes of the head, face, and neck (and under the arms)
4. Palpate neck and trachea
5. Check for JVD

 

Lungs and Thorax

1. Listen to lung sounds front and back
2. Assess respiratory exclusion level
3. Palpate thorax
4. Assess spinal curvature
5. Ask about coughing, respiratory issues

 

Circulatory System

1. Palpate carotid and temporal artery bilaterally
2. Listen to heartbeat and heart valves

 

Gastrointestinal System

1. Inspect abdomen
2. Listen to four quadrants of abdomen for bowel sounds
3. Palpate four quadrants of abdomen for pain/tenderness
4. Ask about problems with bowel or bladder

 

Arms and Hands

1. Assess range of motion and strength in arms/hands
2. Check all pulses in arms
3. Cap refill test on fingernails
4. Check skin turgor
5. Assess sharp and dull sensation on arms

 

Legs and Feet

1. Assess range of motion and strength in legs and ankles
2. Check cap refill on toenails
3. Check pulses of legs and feet
4. Assess sharp and dull sensation on legs
5. Assess gait

 

Genitourinary Exam

1. Check pubic hair for lice and nits
2. Check for tenderness, lumps, lesions

 

Breast Exam

1. Palpate breasts

 

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