HEAD TO TOE ASSESSMENT
Introduction:
o Hello, my name is ….. I’ll be your nurse today may I come in?
o Give privacy
o I’m here to do a head-to-toe assessment is now a good time?
o I’m just double checking for any loose cords or safety hazards before
we get started
o Hand hygiene for 30 seconds
o Body Mechanics! Rails and bed in position
o Can you verify your name and Date of Birth for me please?
o Can you please confirm if you have any allergies?
o Are you feeling any pain today?
o How is your movement today?
o Verbalize that you took vitals, say all normal, and document them
NEURO part 1- Assess Orientation
“I’ll begin by assessing your neurological system by asking you some
questions, and I’ll then assess your Cranial nerves as we continue with the
assessment”
o Where are you right now?
o What day is it?
o Who are you?
o Who is the president of the United States?
o My PT Is A/O x4. Pt is alert to Person, Place and time
o Graphesthesia (draw a # and have a Pt identify) -> BOTH hands.
Verbalize that pt identified correctly
o Stereogensis (Place an object on hand + identify) -> ONE hand.
Verbalize that pt identified correctly.
SKIN INSPECTION
(INSPECTION) “I’ll now assess your arms and legs to inspect your skin” (NOT
TOUCHING PT JUST INSPECT)
, UPPER: Now I’ll be inspecting your skin in the upper extremities, can you
bring your arms out and straight please
o I see that you have the appropriate color for your ethnicity, skin color
is even
o There are no abnormal pigmentations
o No lesions
o The texture is smooth, skin is even throughout the arms
o No edema noted
LOWER: Now I’ll be inspecting your skin in the lower extremities
o I see that you have the appropriate color for your ethnicity, skin color
is even
o There are no abnormal pigmentations
o No lesions
o The texture is smooth, skin is even throughout the arms
o No edema noted
(PALPATION) UPPER: Now I will be palpating to assess your skin
BILATERALLY!!
o Your temperature is warm and dry to touch
o No edema palpated
o I’ll pinch your forearm for turgor; everything looks good I see quick
recoil which indicates proper hydration
o No tenting
o I’ll also assess your nails, they look normal with no signs of
abnormalities
LOWER: Now I will be palpating bilaterally your lower extremities.
o Your temperature is warm and dry
o No edema palpated
o I’ll pinch for turgor on the top of foot; everything looks good I see quick
recoil which indicates proper hydration. NO tenting.
HEAD and FACE
Introduction:
o Hello, my name is ….. I’ll be your nurse today may I come in?
o Give privacy
o I’m here to do a head-to-toe assessment is now a good time?
o I’m just double checking for any loose cords or safety hazards before
we get started
o Hand hygiene for 30 seconds
o Body Mechanics! Rails and bed in position
o Can you verify your name and Date of Birth for me please?
o Can you please confirm if you have any allergies?
o Are you feeling any pain today?
o How is your movement today?
o Verbalize that you took vitals, say all normal, and document them
NEURO part 1- Assess Orientation
“I’ll begin by assessing your neurological system by asking you some
questions, and I’ll then assess your Cranial nerves as we continue with the
assessment”
o Where are you right now?
o What day is it?
o Who are you?
o Who is the president of the United States?
o My PT Is A/O x4. Pt is alert to Person, Place and time
o Graphesthesia (draw a # and have a Pt identify) -> BOTH hands.
Verbalize that pt identified correctly
o Stereogensis (Place an object on hand + identify) -> ONE hand.
Verbalize that pt identified correctly.
SKIN INSPECTION
(INSPECTION) “I’ll now assess your arms and legs to inspect your skin” (NOT
TOUCHING PT JUST INSPECT)
, UPPER: Now I’ll be inspecting your skin in the upper extremities, can you
bring your arms out and straight please
o I see that you have the appropriate color for your ethnicity, skin color
is even
o There are no abnormal pigmentations
o No lesions
o The texture is smooth, skin is even throughout the arms
o No edema noted
LOWER: Now I’ll be inspecting your skin in the lower extremities
o I see that you have the appropriate color for your ethnicity, skin color
is even
o There are no abnormal pigmentations
o No lesions
o The texture is smooth, skin is even throughout the arms
o No edema noted
(PALPATION) UPPER: Now I will be palpating to assess your skin
BILATERALLY!!
o Your temperature is warm and dry to touch
o No edema palpated
o I’ll pinch your forearm for turgor; everything looks good I see quick
recoil which indicates proper hydration
o No tenting
o I’ll also assess your nails, they look normal with no signs of
abnormalities
LOWER: Now I will be palpating bilaterally your lower extremities.
o Your temperature is warm and dry
o No edema palpated
o I’ll pinch for turgor on the top of foot; everything looks good I see quick
recoil which indicates proper hydration. NO tenting.
HEAD and FACE
