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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.
  • Bedside head-to-toe assessment establishes a practical inpatient baseline, while focused assessment narrows to the chief complaint.
  • 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 HEENT assessment: head inspection/palpation; eye checks including PERRLA and basic visual concerns; ear and hearing-aid status; nose concerns; and mouth/throat findings.
  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 assessment: GI symptom review, contour/distension inspection, bowel sounds, light palpation/percussion context, appetite and nutrition cues, and stool pattern concerns.
  11. Perform peripheral vascular assessment: inspect perfusion and color, palpate pulses and edema, and assess for pain, paresthesia, pallor, poikilothermia, or paralysis cues requiring urgent escalation.
  12. Perform GU/activity assessment: voiding pattern, catheter/device status, reproductive symptom concerns as appropriate, mobility/activity tolerance, and ADL safety implications.
  13. 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.
  14. 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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