HEAD-TO-TOE ASSESSMENT
Pre-Procedure Guide ● Gather all necessary PT info from charge nurse report, or
during end-of-shift report.
● Gather all necessary supplies
● Perform hand hygiene.
DURING PROCEDURE GUIDE
General Survey **Knock on the door, open the door, and provide privacy (either
close the door or close the curtain)**
General appearance check: - Introduce yourself, title, and purpose of visit.
● Gender ● Perform safety check (Bed brakes, side rails, clutter, potential
● Signs of distress
● Age and developmental
safety hazards, etc.)
level ● Evaluate ABCs:
● Hygiene, grooming ○ Is the client’s airway compromised?
● Posture, gait (coordinated ○ Assess rate and ease of breathing.
or uncoordinated, posture: ○ Circulation
pain and mood)
● Distribution of body fat ■ Assess for the presence of a radial pulse.
and muscle, ■ Assess skin colour, moisture, and
● Striking features ■ temperature for signs of decreased tissue
● Language, expression perfusion (pale, dusky, cool, or clammy
● Culture skin).
● Odor
● LOO → is the PT A&O to DATE, PLACE, NAME
● Pain ax: LPQRST
○ Ask if PT is experiencing any pain.
○ Ask PT to rate pain on a 1-10 scale.
○ Ask PT to describe the pain:
■ shooting, burning, aching, radiating, pins
and needles?
○ When it started, and what triggered it.
● Ask PT if they require mobility aids, hearing aids, dentures,
etc.
● Ask PT what types of ADLs they can perform independently,
which ones they require assistance.
1
, HEAD-TO-TOE ASSESSMENT
Vital Signs → NOTE: The position of the PT and site of where v/s taken must be
indicated in the documentation. → Laying vs. Sitting, Right vs.
Left arm, etc.
Temperature → Oral, Tympanic, or rectal; 36.5-37.5 degrees
- It’s normal for older adults to have lower body temps than
younger PTs.
Heart Rate → 60-100/min
- Description: strong, regular, weak, absent, etc.
RR → 12-20/min
- Note for signs of accessory muscle use
- Any audible sounds on expiration and/or inspiration?
BP → 120/80; sphygmomanometer used on upper L/R arm
O2 Saturation → 95-100%; Oximeter
Height & Weight
- BMI <18.5 - underweight
- BMI 18.5-24.5 - normal weight
- BMI 25-29.9 - overweight
- BMI over 30 - obesity
HEAD & HAIR
INSPECTION → Inspecting the hair: fine thick and smooth hair , no rash, no
bleeding noted, no lice noted, no grey hair. Also the check
condition and distribution of hair and integrity of the scalp.
a) Terminal hair - long coarse hair, thick, visible
b) Vellus hair - small, soft hair, covering soles/palms
c) Thin, brittle hair (concerning) - screen PT w/ thyroid
stimulating hormone test.
Inspecting the head:
- lesions, abnormalities, bleeding, scratches and assess if the
head is positioned at the midline to the trunk and is upright.
- *If head is tilted to one side - possible indication of unilateral
hearing or visual loss*. Also consider past traumas and scars,
history of headaches and their duration and the PT’s
occupational history. Examine PT’s size, shape and contour of
skull.
PALPATION → Palpating the head:
- round head ,no depression, nodules or masses when palpated (
do this by gently rotating the fingertips down to the midline of
the scalp and along the sides of the head)
- Normal: symmetrical and no depressions, nodules, masses
*If pt has had head trauma, local skull deformities may be
2
Pre-Procedure Guide ● Gather all necessary PT info from charge nurse report, or
during end-of-shift report.
● Gather all necessary supplies
● Perform hand hygiene.
DURING PROCEDURE GUIDE
General Survey **Knock on the door, open the door, and provide privacy (either
close the door or close the curtain)**
General appearance check: - Introduce yourself, title, and purpose of visit.
● Gender ● Perform safety check (Bed brakes, side rails, clutter, potential
● Signs of distress
● Age and developmental
safety hazards, etc.)
level ● Evaluate ABCs:
● Hygiene, grooming ○ Is the client’s airway compromised?
● Posture, gait (coordinated ○ Assess rate and ease of breathing.
or uncoordinated, posture: ○ Circulation
pain and mood)
● Distribution of body fat ■ Assess for the presence of a radial pulse.
and muscle, ■ Assess skin colour, moisture, and
● Striking features ■ temperature for signs of decreased tissue
● Language, expression perfusion (pale, dusky, cool, or clammy
● Culture skin).
● Odor
● LOO → is the PT A&O to DATE, PLACE, NAME
● Pain ax: LPQRST
○ Ask if PT is experiencing any pain.
○ Ask PT to rate pain on a 1-10 scale.
○ Ask PT to describe the pain:
■ shooting, burning, aching, radiating, pins
and needles?
○ When it started, and what triggered it.
● Ask PT if they require mobility aids, hearing aids, dentures,
etc.
● Ask PT what types of ADLs they can perform independently,
which ones they require assistance.
1
, HEAD-TO-TOE ASSESSMENT
Vital Signs → NOTE: The position of the PT and site of where v/s taken must be
indicated in the documentation. → Laying vs. Sitting, Right vs.
Left arm, etc.
Temperature → Oral, Tympanic, or rectal; 36.5-37.5 degrees
- It’s normal for older adults to have lower body temps than
younger PTs.
Heart Rate → 60-100/min
- Description: strong, regular, weak, absent, etc.
RR → 12-20/min
- Note for signs of accessory muscle use
- Any audible sounds on expiration and/or inspiration?
BP → 120/80; sphygmomanometer used on upper L/R arm
O2 Saturation → 95-100%; Oximeter
Height & Weight
- BMI <18.5 - underweight
- BMI 18.5-24.5 - normal weight
- BMI 25-29.9 - overweight
- BMI over 30 - obesity
HEAD & HAIR
INSPECTION → Inspecting the hair: fine thick and smooth hair , no rash, no
bleeding noted, no lice noted, no grey hair. Also the check
condition and distribution of hair and integrity of the scalp.
a) Terminal hair - long coarse hair, thick, visible
b) Vellus hair - small, soft hair, covering soles/palms
c) Thin, brittle hair (concerning) - screen PT w/ thyroid
stimulating hormone test.
Inspecting the head:
- lesions, abnormalities, bleeding, scratches and assess if the
head is positioned at the midline to the trunk and is upright.
- *If head is tilted to one side - possible indication of unilateral
hearing or visual loss*. Also consider past traumas and scars,
history of headaches and their duration and the PT’s
occupational history. Examine PT’s size, shape and contour of
skull.
PALPATION → Palpating the head:
- round head ,no depression, nodules or masses when palpated (
do this by gently rotating the fingertips down to the midline of
the scalp and along the sides of the head)
- Normal: symmetrical and no depressions, nodules, masses
*If pt has had head trauma, local skull deformities may be
2
