Docmoates at 14:44, 5 January 2026

2026-01-05T14:44:47Z

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The '''head to toe assessment''' is a full assessment of the body from head to toe. The purpose of the assessment is to evaluate a patient's overall health, get a baseline, and become aware of any physiological changes or issues across all body systems.

== Steps of the Assessment ==

=== Introduction and Prepration ===
# The nurse introduces themselves.
# The nurse closes the blinds or door to ensure patient privacy.
# The nurse engages in [[hand hygiene]] (ie washing hands, hand sanitizer, etc)
# The nurse checks [[patient identifiers]] (ie patient armband, asking name and date of birth,
# The nurse explains the procedure to the patient.
# The nurse checks any patient orders.
# The nurse asks the patient if they have any questions before we get started.

=== Patient Interview ===
# The nurse identifies the [[chief complaint]] in the chart and by asking the patient what brings them in today.
# The nurse goes through past medical history.
## This includes past surgeries.
# The nurse goes through family history.
# The nurse goes through current medical history.
## The nurse identifies any patient allergies.
## The nurse identifies any patient medications.
## The nurse goes through social screening.
### Drugs
### Alcohol
### Smoking
### Sex
### Physical Safety
## The nurse identifies any social determinants of health.
### Insurance
### Vaccines
# The nurse assesses the patient to be alert and awake or stupor and non-arousable.
## Speech and Hearing
# The nurse assesses the patient to orientation.
## Person (can be identified by patient identifiers above)
## Time
## Place
## Location
## Situation
# Verbalize that the assessment will be done on bare skin.

==== General Inspection ====

# While conduction the nursing interview, the nurse should begin evaluation.
## Skin Color
## Facial Expression
## Mobility
## Dress and Posture

=== Vital Signs & Pain ===

==== Manual Blood Pressure ====

# Apply correctly sized sphygmomanometer (blood pressure cuff) 2-5 cm (1-2 inches) above the brachial artery (the main artery of the upper arm)
# Position patient with arm supported at heart level and feet flat on the floor.
# Ask patient what their average blood pressure is.
# Obtain the patient’s blood pressure:
## Put on the stethoscope with earpieces angled forward, place the diaphragm over the brachial artery & inflate cuff 30mmHg above estimated systolic pressure (top number) to avoid missing an auscultatory gap
## Deflate cuff 2mmHg per second while listening for Korotkoff sounds, noting when first Korotkoff sound appears (systolic BP) & the last audible Korotkoff sound (diastolic BP)(bottom number)
## Continue to slowly deflate the cuff for a bit longer to make sure the Korotkoff sounds don’t reappear, and then rapidly deflate the cuff

=== Head, Eyes, Ears, Nose, Mouth, Throat (HEENT) ===

==== Eyes ====

# The nurse will examine various parts of the eye:
## Sclera (white outer layer of the eye)
## Conjunctiva (mucous membrane that covers the white part of the eye)
## Pupil Size
## Pupillary Response (shining pen light into the eye and observing the response)

==== Nose ====

# The nurse will examine various parts of the nose:
## Nares (nostrils)
### Check to ensure nasal passages are open and unobstructed
### Check for congestion/drainage.

==== Mouth ====

# The nurse will examine various parts of the mouth:
## Check to make sure the mucous membranes are smooth, moist, and observe color

[[Category:NSG 522 Clinical I]]
[[Category:Nursing]]

Head to Toe Assessment - Revision history

Docmoates at 14:44, 5 January 2026