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Head-to-Toe Assessment Checklist

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Head-to-Toe Assessment Checklist

Key Points

  • Use a consistent sequence to reduce missed findings and improve handoff clarity.
  • Start with safety, identity, and primary survey before detailed system assessment.
  • Integrate subjective and objective data during each system check.
  • Escalate unanticipated findings immediately per agency protocol.

Equipment

  • Stethoscope and penlight
  • Watch with second hand
  • Gloves, hand sanitizer, and indicated PPE
  • Wound measurement tool (if wounds are present)

Procedure Steps

  1. Gather required supplies, perform hand hygiene, and disinfect stethoscope before patient contact.
  2. Enter with safety protocol: knock, assess transmission-based precautions, introduce role/purpose/time estimate, protect privacy/dignity, and confirm two identifiers.
  3. Perform a primary survey for immediate stability (airway, breathing, circulation, mental status) and activate emergency support if unstable.
  4. Complete a general survey (appearance, behavior, mood, mobility/coordination, communication, nutrition/fluid cues), address immediate needs (for example toileting, glasses, hearing aids), and clarify chief concern with PQRSTU-based prompts.
  5. Obtain/analyze vital signs and pain/discomfort status; escalate out-of-range or clinically concerning findings promptly.
  6. Perform neuromuscular assessment: symptoms (headache/dizziness/weakness/numbness/tremor/swallowing/balance/falls), orientation, PERRLA, bilateral strength/sensation, and fall-risk screening.
  7. Perform head/neck/eye/ear/oral assessment: vision/hearing aids, oral cavity and swallow, external inspection, and lymph-node checks per policy.
  8. Perform cardiovascular assessment: chest-symptom history, skin color/perfusion, JVD context, edema/DVT cues, bilateral pulse comparison, capillary refill, heart-sound auscultation, and apical pulse for one minute.
  9. Perform respiratory assessment: dyspnea/cough/smoking history, breathing pattern/effort, chest movement, tracheal alignment, bilateral lung auscultation, oxygen-device details, and tracheostomy/site or sputum characteristics when present.
  10. Perform abdominal/GU assessment: GI/GU symptom review, contour/distension inspection, bowel sounds, light palpation for tenderness/masses, weight and input/output trends, and device/stoma status (enteral tube, urinary catheter, ostomy) when present.
  11. Perform integumentary assessment: global skin findings, pressure-point breakdown screening, wound/pressure-injury review, IV-site condition, edema grading, and palpation for temperature/moisture/texture changes.
  12. Reposition for comfort, complete room safety checks (call light, bed low/locked, rails/table, fall-hazard scan), remove PPE as indicated, repeat hand hygiene/stethoscope cleaning, document findings, and report unanticipated findings per policy.

Escalation Priority

Do not delay escalation when primary-survey instability or new high-risk findings appear during the checklist.

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