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Skills
Head-to-Toe Assessment
Extended Text
ALERT
• If the patient is in acute distress, immediately assess the affected body system(s). Assessment findings may change the direction of the
examination.
• Report a pattern of findings that indicates abuse to a social service center (refer to state guidelines). Obtain immediate consultation with the
practitioner, social worker, and other support staff to facilitate placement of the patient in a safer environment.

OVERVIEW
A head-to-toe examination covers the following areas: assessment of the head and face, neck, upper and lower extremities, back, chest, lungs, breasts,
precordium, and abdomen, as well as the neurologic system (sensory and motor) and genitalia.

SUPPLIES
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EDUCATION
• Teach the patient about the normal vital sign ranges for the patient’s age and physical condition and the normal weight for the patient’s height
and body frame.
• If the patient is on a prescribed diet, discuss any problems the patient has in diet preparation or food selection.
• Discuss the patient’s goal for pain management.
• Identify the patient’s preferences for nonpharmacologic pain treatment modalities.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

• Organize your equipment ahead of time to avoid interruption and delay.
• Provide a warm, private, quiet room for examination.
• Have the patient empty his or her bladder before you begin the examination.
• Provide privacy while the patient removes his or her street clothes and puts on a gown.
• Perform hand hygiene and swab your stethoscope with alcohol in front of the patient to reassure him or her that this precaution has been taken.
• Explain to the patient that he or she will be sitting or lying down for most of the examination and that it will involve a combination of inspection
("looking"), palpation ("feeling"), and listening through the stethoscope.
• Assure the patient that the examination does not normally cause pain or discomfort, and that none of the tests are unpleasant.
• Explain to the patient that he or she will participate in a wide variety of functions.
• Watch the patient's face and body language for signs of undue distress during the examination.
• Screen for history of opioid dependence.
• Verify the patient’s actual weight in kilograms. Reweigh the patient if appropriate.1

DELEGATION
Patient assessment may not be delegated to nursing assistive personnel (NAP). However, other health care specialists may be part of the evaluation
process when areas of concern are identified.

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PROCEDURE
1. Provide for patient privacy and perform hand hygiene.
2. Introduce yourself to the patient and family, if present.
3. Identify the patient using two identifiers, such as name and date of birth or name and account number, according to agency policy. Compare
these identifiers with the information on the patient’s identification bracelet.
4. Explain the procedure to the patient and ensure that he agrees to treatment.

General Inspection
1. Perform an initial focused inspection to detect signs of disease or distress.
a. Assess the patient's mobility, posture, build, and any deformities, as well as dress and grooming.
b. Assess skin color, facial expression, alertness, and eye contact.
c. Assess speech, hearing, or vision concerns.
d. After the patient empties his bladder, make initial measurements: Obtain the patient's height and weight.
e. Check distance vision with a Snellen Chart, which tests cranial nerve II.
f. Take the patient's vital signs.
g. Assess the patient’s pain status using criteria per the organization’s practice. Consider the patient’s age, condition, and ability to
understand.2

Head and Face

1. With the patient seated, inspect his skin, eyes, ears, and skull for symmetry and any abnormalities.
a. Inspect and palpate the scalp and hair. Note hair texture, distribution, and quantity.
b. Palpate the temporomandibular joints. Ask the patient to open and close his mouth.
c. Palpate the facial bones and frontal and maxillary sinuses. Ask the patient if there is any tenderness. If palpation causes discomfort,
percuss the sinuses.
d. Test cranial nerve VII by asking the patient to perform these facial movements: Grind your teeth; Close your eyes shut; Wrinkle your
forehead; Smile; Stick out your tongue; Puff out your cheeks.
e. Test cranial nerve V by asking the patient to close his eyes and tell you when he feels a cotton wisp; check for perception of light touch
on his face, forehead, cheeks, and chin.
2. Examine the eyes by first inspecting the lids, brows, sclerae, and other external structures.
a. Palpate the lacrimal glands.
b. Test the patient's near vision with a Rosenbaum Chart (which also checks cranial nerve II).
c. Dim the lights to assess the pupillary response to light.
d. Assess the pupillary response to accommodation.
e. Check the corneal light reflex. If light does not reflect symmetrically from both corneas, perform the cover/uncover test.
f. Return lights to normal level to assess extraocular movements (which evaluate cranial nerves III, IV, and VI).
g. Assess visual fields (which evaluate cranial nerve II).
h. Again dim the lights and use an ophthalmoscope to test the red reflex.
i. Inspect the retina including its optic disc, retinal vessels, and other structures.
3. Examine the ears, noting alignment, placement and surface characteristics and palpating the auricles.
a. Evaluate hearing such as with the whisper test to check cranial nerve VIII.
b. Use an otoscope to inspect each external auditory canal and tympanic membrane.
c. Perform the Weber and Rinne tests, comparing bone conduction of sound to air conduction.
4. Examine the nose: observe the septum and check nostril patency.
a. Use a nasal speculum to inspect the mucosa, septum and turbinates.
b. Test the patient's sense of smell (which evaluates cranial nerve I).
5. Examine the mouth and pharynx.
a. Inspect the lips, buccal mucosa, teeth, gums, and tongue.
b. Inspect the oropharynx.
c. Have the patient say "Ah" (which tests cranial nerves IX and X).
d. Check the gag reflex (which also tests cranial nerves IX and X).
e. Check taste response by using various solutions (which tests cranial nerves VII and IX).

Neck
6. Inspect the neck structures, including the thyroid gland and jugular veins.
a. Test neck range of motion without resistance, then with resistance.

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b. Have the patient shrug against your resistance (which tests cranial nerve XI).
c. Palpate the carotid arteries–one at a time, the position of the trachea, and the thyroid gland.
d. Palpate the regional lymph nodes: the preauricular, postauricular, tonsillar, submaxillary, submental, superficial cervical, posterior
cervical, deep cervical, and supraclavicular nodes.
e. Use the stethoscope bell to auscultate for bruits in the carotid arteries, as well as the thyroid gland if it is enlarged.

Upper Extremities
7. Observe the hands, arms, and shoulders, noting skin and nail characteristics.
a. Inspect muscle mass and strength.
b. Check joint range of motion.
c. Assess the radial pulses and brachial pulses.
d. Palpate the epitrochlear nodes.

Back
8. With the patient's gown lowered to the waist, examine his back and posterior chest.
a. Note the skin, thoracic shape, shoulder symmetry, and muscle development.
b. Inspect and palpate the spine and scapulae. Percuss the spine.
c. Percuss the costovertebral angle with your fist to test for kidney tenderness.

Lungs
9. Observe for excursion.
a. Note the respiratory depth, rhythm, and pattern.
b. With your thumbs at the tenth rib, check for thoracic expansion during respiration.
c. Instruct the patient to say "99," while you palpate for tactile fremitus.
d. Percuss the posterior and lateral chest walls for resonance.
e. Percuss for diaphragmatic excursion along the right and left scapular lines by first having the patient inhale a deep breath and holding
it, then exhaling and holding it; mark the difference with a skin marker.
f. Instruct the patient to breathe normally, then take deep breaths while you auscultate for breath sounds. Note characteristics of any
breath sounds and any adventitious sounds.

Chest, Breasts, and Precordium

10. Facing the patient, perform a general visual inspection.
a. Observe the skin, muscles, symmetry, and respirations.
b. Inspect for pulsations or heaving, and palpate the chest wall.
c. Palpate the precordium for unusual pulsations and to locate the point of maximal impulse.
d. Palpate the lymph nodes in the subclavian, central axillary, and brachial areas, and the axillae.
e. Percuss systematically for resonance, comparing sounds bilaterally.
f. Auscultate for heart sounds in the aortic area, pulmonic area, second pulmonic area, tricuspid area, and mitral or apical area.
g. Inspect the breasts in four positions: patient sitting up straight; patient sitting up straight with both arms raised and both hands placed
behind the head; patient sitting with hands on hips and shoulders rolled forward; patient sitting and leaning slightly forward.
h. Palpate the breasts, using the chest wall sweep and bimanual digital palpation.
i. Help the patient recline at a 45 degree angle and inspect the precordium for unexpected visible pulsations.
j. Examine his jugular vein pulsations and estimate his jugular-venous pressure.
k. Lower the patient into the supine position, and palpate each breast systemically with her arm raised above her head.
l. Palpate the chest wall again for thrills, heaves, and pulsations.
m. Auscultate the heart systematically.
n. To hear certain heart sounds better, turn the patient on his left side and auscultate again.

Abdomen
11. Have the patient rotate back to supine, expose the patient's abdomen, and inspect abdominal skin characteristics and contour, noting any
pulsations or movement.
a. Auscultate for bowel sounds with the diaphragm of the stethoscope. If you find an abnormality, listen in all four quadrants.
b. Switch to the bell to auscultate for bruits and venous hums over the aorta, renal arteries, iliac arteries, and femoral arteries.
c. Percuss in all four quadrants to detect resonance or dullness.
d. Percuss in the right mid-clavicular line to estimate the liver span and percuss in the left midaxillary line for splenic dullness.
e. Alert the patient to tell you if palpation causes any tenderness; then palpate lightly, moderately, and then deeply in all four quadrants.

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f. Palpate for specific organs including the liver in the right costal margin, the spleen in the left costal margin, the kidneys in the left and
right flanks, and the aorta, slightly to the left of the midline.
g. Stroke each quadrant to test the abdominal reflexes.
h. Ask the patient to raise his head so you can inspect the abdominal muscles.
i. Palpate the inguinal area to assess the femoral pulses and inguinal lymph nodes.

Lower Extremities
12. Adjust the drapes to expose the patient's lower extremities and inspect his feet and legs, noting skin characteristics, hair distribution, muscle
mass, and configuration.
a. Palpate the temperature and texture of the feet and legs.
b. Test for edema.
c. Assess the dorsalis pedis, posterior tibial, and popliteal pulses.
d. Assess toe ranges of motion by asking the patient to bend his toes up and down.
e. Assess range of motion of the feet, ankles, and knees. Ask the patient to bend the soles of your feet towards each other, and away from
each other, to rotate his ankles in and now out, and to bend the knees and straighten them.
f. Examine the hips, palpating them for signs of stability and testing their range of motion and strength. Have the patient raise each leg,
then bring each knee to the chest and return them to a straight position; swing each leg to the side, then across the body; bend each
knee and rotate it in, then straighten it out and cross his ankle over his knee.
g. Assess musculoskeletal function by watching as the patient moves to a seated position. Note coordination, muscle use, and ease of
movement.

Neurologic System
13. Assess sensory function, fine motor function and coordination, position sense, reflexes, spinal range of motion, proprioception and cerebellar
function, and balance as follows:
a. Test sensory function (have the patient distinguish sharp from dull) in the forehead, face, lower arms, hands, lower legs, and feet.
b. Test vibratory function in the patient's wrists and ankles.
c. Assess two-point discrimination on the patient's palms, thighs, and back.
d. Test stereognosis and graphesthesia.
e. Use specific tasks to test the patient's fine motor function and coordination. Have the patient touch each finger to the thumb of the
same hand; use his index finger to touch his nose and then to your finger; run his heel down the shin of the opposite leg.
f. Test position sense in the upper and lower extremities. For instance, have the patient close his eyes and tell you the position into which
you move his toe.
g. Test spinal reflexes bilaterally, including the biceps, triceps, brachioradialis, patellar, and Achilles reflexes, as well as the plantar reflex on
the soles of both feet.
h. Assess the spine with the patient standing; palpate the spine for tenderness and inspect spinal curvature by having the patient bend
forward and backward; have the patient bend to each side and twist in each direction, holding the patient's hips if the patient is
unsteady.
i. Observe the patient's gait.
j. Check proprioception and cerebellar function beginning with the Romberg test.
k. Check balance by having the patient walk heel-to-toe, closing his eyes and standing on each foot separately, then opening his eyes and
hopping on each foot.

Genitalia
14. Assess male genitalia and related structures with the patient in standing position.
a. Inspect the pubic hair, penis, scrotum, and urethral meatus.
b. Palpate the scrotal contents.
c. Test for inguinal and femoral hernias.
d. Complete your assessment with the male patient leaning over the exam table: inspect the patient's sacrococcygeal and perianal areas,
and palpate his anal sphincter. Palpate circumferentially for a rectal mass.
e. If needed, obtain a rectal culture.
f. Palpate the prostate gland and seminal vesicles.
g. Withdraw your finger. If stool is present on your glove, note its characteristics and test it for occult blood if indicated.
15. Assess female genitalia and related structures with the patient in the lithotomy position, draped appropriately.
a. Examine her external genitalia, first inspecting the pubic hair, labia, clitoris, urethral and vaginal openings, perineal and perianal areas,
and anus.
b. Palpate the labia and Bartholin glands and milk the Skene glands.

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c. Assess the internal genitalia starting with a speculum examination. Through the speculum, inspect the vagina and cervix and collect
specimens for a pap smear and other tests as needed.
d. Perform bimanual palpation to further assess the vagina and cervix as well as the uterus and adnexa.
e. Perform a rectovaginal examination to assess the rectovaginal septum and broad ligaments.
f. Perform a rectal exam. Assess anal sphincter tone and palpate for rectal masses.
g. If needed, obtain a rectal culture. After removing your gloved finger, note the stool characteristics and test for occult blood if indicated.

MONITORING AND CARE

• Ask if the patient has any questions or concerns about the examination.
• If corrective lenses have been removed for the examination, return them to the patient.
• Provide tissues so the patient can clean off any remaining lubricant.
• Assist the patient off the examination table.
• Provide privacy while the patient returns to street clothes.
• In your discussion with the patient, be clear that this is a basic examination and that any abnormal findings are not definitive but would suggest
the need for a more specialized examination.
• Patient teaching should include the principles of breast self-examination for women, testicular examination for men, and self-examination of the
skin for all.
• Follow-up teaching should focus on risk factors that were revealed by the history obtained during the subjective portion of the examination.
Tobacco use is a primary concern, and other opportunities to promote health include discussions of occupational exposures, proper vaccinations,
and use of alcohol and drugs.
• Discuss the need to be vigilant regarding moles, and familiarize the patient with the ABCDE technique of tracking the characteristics of moles, if
appropriate.
• Advise the patient about the need for continued screening—as appropriate—for glaucoma; cholesterol; hypertension; or breast, prostate,
colorectal, or testicular cancer.
• Provide specific information about when the patient will hear from you or another clinician about the results of the examination.

DOCUMENTATION
Documentation Guidelines:
• Record all relevant data in a timely fashion to avoid relying on memory for important clinical details.
• For required information that is not available, document the reason for the absence of information rather than simply leaving the file blank.
• Be sure to only use abbreviations accepted by your institution.

Sample Documentation:
Refer to the specific sample documentation for each of the individual assessment skills:

• Assessing the Abdomen (HA_01)

• Assessing the Breasts and Axillae (HA_02)
• Assessing the Ears (HA_03)
• Assessing the Eyes (HA_04)
• Assessing the Female Genitalia and Rectum (HA_05)
• Assessing the Head and Neck and Lymphatics (HA_06)
• Assessing the Heart and Neck Vessels (HA_07)
• Assessing the Male Genitourinary, Rectum, and Prostate (HA_08)
• Assessing the Musculoskeletal System (HA_09)
• Assessing the Neurologic System: Mental Status and Cranial Nerves (HA_10)
• Assessing the Neurologic System: Motor and Sensory Functions (HA_11)
• Assessing the Nose, Mouth, and Throat (HA_12)
• Assessing the Peripheral Vascular System (HA_13)
• Assessing the Skin, Hair, and Nails (HA_14)
• Assessing the Thorax and Lungs (HA_15)

PEDIATRIC CONSIDERATIONS
General Inspection
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Observe a child at play to generally evaluate his musculoskeletal and neurologic systems while building rapport.

Upper Extremities
For a young child, use the parent's lap as an exam table and begin with the arms and legs. Then assess the head and neck, and the chest, heart, and
lungs. This allows the child time to acclimate to your examination.

OLDER ADULT CONSIDERATIONS

Neurological System
For an older patient, remember that neurologic tests may require a more intense stimulus and that reaction time may be longer.

Genitalia
For an older male patient, you may need to use alternate positioning such as the knee-chest position, to prevent tiring and enhance comfort.

REFERENCES
1. Institute for Safe Medication Practices (ISMP). (2017). 2018-2019 Targeted medication safety best practice for hospitals. Retrieved March 7,
2019, from https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf
(https://www.ismp.org/sites/default/files/attachments/2019-01/TMSBP-for-Hospitalsv2.pdf ) (Level VII)
2. Joint Commission, The. (2017). R3 report: Requirement, rationale, reference. Retrieved May 15, 2018 from
https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf
(https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf ) (Level VII)

Elsevier Skills Levels of Evidence

• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
• Level V - Descriptive or qualitative studies
• Level VI - Single descriptive or qualitative study
• Level VII - Authority opinion or expert committee reports

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