Registered Nurse how-to
How to Perform a Head-to-Toe Nursing Assessment
A systematic head-to-toe assessment helps nurses establish a baseline and catch changes early.
A systematic head-to-toe assessment helps nurses establish a baseline and catch changes early. In short: perform; note; take, then complete the remaining steps below.
Step by step
Perform hand hygiene, introduce yourself, confirm identity with two identifiers and explain the assessment.
Note general appearance, level of consciousness and orientation to person, place, time and situation.
Take vital signs, including pain and oxygen saturation.
Assess head and neck, then the cardiovascular system: heart sounds, peripheral pulses, capillary refill and edema.
Assess the respiratory system: rate, effort and lung sounds in all fields, front and back.
Assess the abdomen (bowel sounds, tenderness, last bowel movement) and genitourinary status.
Check skin integrity, IV sites, wounds and drains, then mobility, strength and fall risk; document findings and report abnormalities.
Safety reminders for registered nurses
- Use barcode scanning and the rights of medication administration for every dose
- Follow standard and transmission-based precautions and wear appropriate PPE
- Use safe patient-handling equipment to prevent back injuries
- Speak up and escalate concerns through the chain of command
Key terms
NCLEX-RN · Nursing process (ADPIE) · Head-to-toe assessment · SBAR · Handoff report · Rapid response: see the full registered nurse glossary.