13 2.5 Head-to-Toe Assessment

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

• Perform hand hygiene.
• Check room for contact precautions.
• Introduce yourself to patient.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain process to patient.
• Be organized and systematic in your assessment.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure patient’s privacy and dignity.
• Assess ABCCS (airway, breathing, circulation, consciousness, safety)/suction/oxygen/safety.
• Apply principles of asepsis and safety.
• Check vital signs.
• Complete necessary focused assessments.

Steps

Additional Information

• Affect/behaviour/anxiety
• Level of hygiene
• Body position
• Patient mobility
• Speech pattern and articulation

2. Skin, hair, and nails:

• Inspect for lesions, bruising, and rashes.
• Palpate skin for temperature, moisture, and texture.
• Inspect for pressure areas.
• Inspect skin for edema.
• Inspect scalp for lesions and hair and scalp for presence of lice and/or nits.
• Inspect nails for consistency, colour, and capillary refill.

Redness of the skin at pressure areas such as heels, elbows, buttocks, and hips indicates the need to reassess patient’s need for position changes.

Unilateral edema may indicate a local or peripheral cause, whereas bilateral-pitting edema usually indicates cardiac or kidney failure.

Check hair for the presence of lice and/or nits (eggs), which are oval in shape and adhere to the hair shaft.

• Inspect eyes for drainage.
• Inspect eyes for pupillary reaction to light.
• Inspect mouth, tongue, and teeth for moisture, colour, dentures.
• Inspect for facial symmetry.

Slow pupillary reaction to light or unequal reactions bilaterally may indicate neurological impairment.

Dry mucous membranes indicate decreased hydration.

Facial asymmetry may indicate neurological impairment or injury. Unusual findings should be followed up with a focused neurological system assessment.

• Inspect:
  • Expansion/retraction of chest wall/work of breathing and/or accessory muscle use
  • Jugular distension
• Auscultate:
  • For breath sounds anteriorly and posteriorly
  • Apices and bases for any adventitious sounds
  • Apical heart rate
• Palpate:
  • For symmetrical lung expansion

Use of accessory muscles may indicate acute airway obstruction or massive atelectasis.

Jugular distension of more than 3 cm above the sternal angle while the patient is at 45º may indicate cardiac failure.

The presence of crackles or wheezing must be further assessed, documented, and reported. Unusual findings should be followed up with a focused respiratory assessment.

Note the heart rate and rhythm, identify S1 and S2, and follow up on any unusual findings with a focused cardiovascular assessment.

• Inspect:
  • Abdomen for distension, asymmetry
• Auscultate:
  • Bowel sounds (RLQ)
• Palpate:
  • Four quadrants for pain and bladder/bowel distension (light palpation only)
• Check urine output for frequency, colour, odour.
• Determine frequency and type of bowel movements.

Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileum.

Hypoactive or absent bowel sounds may be present after abdominal surgery, or with peritonitis or paralytic ileus.

Pain and tenderness may indicate underlying inflammatory conditions such as peritonitis.

Unusual findings in urine output may indicate compromised urinary function. Follow up with a focused gastrointestinal and genitourinary assessment.

Unusual findings with bowel movements should be followed up with a focused gastrointestinal and genitourinary assessment.

• Inspect:
  • Arms and legs for pain, deformity, edema, pressure areas, bruises
  • Compare bilaterally
• Palpate:
  • Radial pulses
  • Pedal pulses: dorsalis pedis and posterior tibial
  • CWMS and capillary refill (hands and feet)
• Assess handgrip strength and equality.
• Assess dorsiflex and plantarflex feet against resistance (note strength and equality).
• Check skin integrity and pressure areas.

Palpate pulses for symmetry in rate and rhythm. Asymmetry may indicate cardiovascular conditions or post-surgical complications.

Unequal handgrip and/or foot strength may indicate underlying conditions, injury, or post-surgical complications.

CWMS: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion.

Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.

Palpate and inspect capillary refill and report if more than 3 seconds.

To check capillary refill, depress the nail edge to cause blanching and then release. Colour should return to the nail instantly or in less than 3 seconds. If it takes longer, this suggests decreased peripheral perfusion and may indicate cardiovascular or respiratory dysfunction. Unusual findings should be followed up with a focused cardiovascular assessment.

Clubbing of nails, in which the nails present as straightened out to 180 degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis.

• Inspect back and spine.
• Inspect coccyx/buttocks.

Check skin integrity and pressure areas, and ensure follow-up and in-depth assessment of patient mobility and need for regular changes in position.

• Inspect for drainage, position, and function.
• Assess wounds for unusual drainage.

Assess wounds for large amounts of drainage or for purulent drainage, and provide wound care as indicated.

• Check if full or partial weight-bearing.
• Determine gait/balance.
• Determine need for and use of assistive devices.