Hello future nurses! Here is an outline of how to conduct a complete head to toe assessment. Included in this outline are some tips that will help you develop a routine and gain confidence when assessing your patients. Let's get started!

1. Initial Assessment 

As soon as you walk into the exam room the assessment begins.The nurse should note:

• The patient’s general appearance (Hygiene, Dress, Affect)
• Posture (Is the patient sitting/standing with good posture?)
• If the patient is alert/oriented (Can they respond to questions appropriately?)
• Signs of distress (Labored breathing, Pallor, Confusion)
• Subjective Data (Medical History, Allergies, Pain)

These initial assessments are essential when assessing a patient’s mental status. During this time, you should also obtain subjective data from the patient to have a better understanding of why they are in the office. You can do this by asking how they are feeling or ask what they are in the doctor's office for today. 2. Vital Signs After taking the time to speak with the patient, ask permission to collect their vital signs. Collecting vitals allows you to comfortably approach the patient with touch for the first time during the interview. TIP: Remember to ALWAYS ask permission before touching the patient and explain each one of the assessments you will be performing. 3. Hair/Skin/Nails When performing assessments on different areas of the body (ex. abdomen, arms, or legs), you should note abnormal findings of the skin and hair on these areas. The nurse should assess nails for:

• Delayed capillary refill
• Clubbing
• Fungus

Abnormal findings include: Uneven hair distribution, color abnormalities (Pallor, Cyanosis, Erythema), extremes in temperature or moisture of skin, decreased skin turgor, lesions 4. Head

• Assess for symmetry, size, and shape.
• Ask the patient to smile and raise eyebrows (Assessing Facial Nerve)
• Palpate the patient’s scalp.

Abnormal findings include: Tenderness, swelling, asymmetry 5. Neck

• Inspect and palpate lymph nodes and glands
• Have a patient perform neck range of motion
• Have the patient shrug their shoulders to assess the Spinal Accessory Nerve.

Abnormal findings include: Deviation of the trachea, enlarged thyroid gland or lymph nodes 6. Eyes

• Inspect external structures
• Check for red reflex using the otoscope.
• Check pupils for PERRLA (Pupils Equal Round Reactive to Light and Accommodation)
• Assess extraocular movements to assess functions of the Oculomotor, Trochlear, and Abducens cranial nerves.
• Perform Visual Acuity Test (Assessing Optic Nerve)

Abnormal findings include: Discharge, lesions, redness, no PERRLA 7. Nose and Sinuses

• Assess for nasal patency in each nostril by having the patient blow out of each nostril. Then use a scented object such as vanilla or peppermint in each nostril to see if the patient can smell. This exam assesses the function of the Olfactory nerve.
• Inspect inside the nose with an otoscope.
• Inspect septum, determine the location.
• Palpate sinuses to determine if tenderness is present.

Abnormal findings include: Deviated septum, nasal polyps, discharge 8. Ears

• Inspect external ear with an otoscope
• Test Hearing with Whisper Test (Assessing Vestibulocochlear Nerve)
• Note the appearance of the tympanic membrane and cerumen present.

Abnormal findings include: Discharge, lesions, abnormal light reflection on tympanic membrane, scarring of the tympanic membrane. 9. Mouth and Throat

• Inspect the oral cavity
• Inspect lips
• Inspect the tonsils and uvula
• Have the patient move their tongue from side to side (Assessing Hypoglossal Nerve)
• Assess the patient's ability to taste (salt vs sugar), ability to swallow, and gag reflex. (Assessing the Glossopharyngeal and Vagus Nerves)

Abnormal findings include: Swelling, asymmetry, lesions, cyanosis, dry/cracked lips, cleft lip, discoloration, dryness, hairy tongue, enlarged tonsils, cleft palate. 10. Chest (Cardiovascular and Respiratory) Cardiovascular

• Palpate and Auscultate Apical Pulse
• Auscultate heart sounds with the diaphragm and bell of the stethoscope. Areas: Aortic, Pulmonic, Erb's Point, Tricuspid, and Mitral

Abnormal findings include:Pericardial friction rub, murmur, presence of S3 or S4, irregular heart beat. Respiratory

• Compare anterior-posterior chest diameter to transverse chest diameter. Normal is 2:1.
• Chest expansion
• Effort to breathe
• Auscultate lungs

Abnormal Findings include: Retraction, labored breathing, asymmetrical chest expansionRetraction, gasping for air, Bradypnea or Tachypnea, absent lung sounds, crackles, wheezes, Stridor, and Pleural friction rub. 11. Abdomen

• Inspect
• Auscultate bowel sounds in all quadrants.
• Palpate

Abnormal findings include: Abnormal pulsations, Hypo/Hyperactive Bowel sounds, purple or dark red skin pigmentation, tenderness, mass/protrusion. 12. Peripheral Vascular

• Inspect and palpate upper and lower extremities

Abnormal findings include: Delayed capillary refill, bounding or absent pulses, presence of Arterial or Venous Disease, skin discolorations. 13. Neurological & Musculoskeletal 

• Palpate joints
• Demonstrate Range of Motion
• Assess Deep Tendon Reflexes

Abnormal findings include: Crepitus, swelling , pain/tenderness, limited or no range of motion, hyperactive response, pain, tenderness, no response, hyperactive response. If the tap triggers a repeated tendon reflex: Assess Balance - Romberg test; Assess Gait by having the patient walk across the room and walk back towards you in a straight line, heel to toe. 14. Assessment Conclusion

• Let the patient know when the assessment is complete.
• Ask the patient if they have any questions or concerns.

15. Practice…Practice…Practice

• It takes a lot of practice to perfect your head to toe assessment.
• When in your clinical rotations, ask your nurse if you can assess the patient; this will help you gain confidence and skills as you practice with different clients.