Nursing Student Head to Toe Assessment Sample Charting Entry

Examples of Documentation: Forms and Formats (Nursing)
Head-to-Toe Nursing Assessment
The sequence for performing a head-to-toe assessment is:



Inspection

Palpation
Percussion
Auscultation
However, with the abdomen it is changed where auscultation is performed second instead of last. The order for the abdomen would be:

Inspection

Auscultation
Percussion
Palpation (palpation and percussion are done last to prevent from altering bowel sounds)
Provide privacy, perform hand hygiene, introduce yourself to the patient, and explain to the patient that you need to conduct a head-to-toe assessment

Ask the patient to confirm their name and date of birth by looking at the patient’s wrist band (this helps assess orientation to person and confirms you have the right patient). In addition, ask the patient where they are, the current date, and current events (who is the president and vice president) etc.

Collect vital signs: heart rate, blood pressure, temperature, oxygen saturation, respiratory rate, pain level

NOTE: Before even assessing a body system, you are already collecting important information about the patient. For example, you should already be collecting the following information :

Looking at the overall appearance of your patient: do they look their age, are they alert and able to answer your questions promptly or is there a delay?
Does their skin color match their ethnicity; does the skin appear dry or sweaty?
Is their speech clear (not slurred)?
Do they easily get out of breath while talking to you (coughing etc.)?
Any noted abnormalities?
How is their emotion status (calm, agitated, stressed, crying, flat affect, drowsy)?
Can they hear you well (or do you have to repeat questions a lot)?
Normal posture?
Abnormal smells?
How is their hygiene?
Assess height and weight and calculate the patient’s BMI (body mass index).



Below 18.5 = Underweight
18.5-24.9 = Normal weight
25.0-29.9 = Overweight
30.0 or Higher = Obese

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