Key Takeaway
Always use a systematic, head-to-toe approach — never skip systems based on the chief complaint. Patients often can't tell you what's wrong, and your assessment may be the only way to detect a developing complication before it becomes a crisis.
The head-to-toe assessment is performed at the beginning of every shift and whenever a patient's condition changes. It takes 10–15 minutes when done efficiently and provides the baseline data you need to detect deterioration early. Here's a system-by-system breakdown of what to assess and what to look for.
General Appearance & Vital Signs
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| General appearance | Alert, oriented, well-nourished, no acute distress | Confusion, cachexia, diaphoresis, labored breathing |
| Level of consciousness | Alert and oriented ×4 (person, place, time, event) | Confusion, lethargy, obtundation, stupor, coma |
| Vital signs | BP 90–120/60–80, HR 60–100, RR 12–20, Temp 97.8–99.1°F, SpO₂ ≥95% | Hypo/hypertension, brady/tachycardia, hypo/hyperthermia, hypoxia |
| Pain assessment | 0/10 or patient's baseline | Any new or worsening pain — assess PQRST |
Neurological
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| Orientation | Oriented to person, place, time, and event | Disorientation — note which components are affected |
| Pupils | PERRLA — equal, round, reactive to light and accommodation | Unequal (anisocoria), non-reactive, pinpoint (opioids), blown (herniation) |
| Motor strength | 5/5 strength bilaterally in all extremities | Weakness, paralysis, asymmetry — document side and grade (0–5 scale) |
| Sensation | Intact sensation to light touch bilaterally | Numbness, tingling, absent sensation — document dermatomal pattern |
| Reflexes | 2+ (normal) deep tendon reflexes | 0 (absent) or 4+ (hyperreflexia) — note clonus, Babinski sign |
Cardiovascular
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| Heart sounds | S1 and S2 present, regular rate and rhythm | S3 (heart failure), S4 (hypertension/MI), murmurs — grade I–VI |
| Peripheral pulses | 2+ bilaterally in radial, pedal, posterior tibial | Diminished (1+), absent (0), bounding (3+/4+) — note asymmetry |
| Capillary refill | < 2 seconds | > 2 seconds — suggests poor perfusion |
| Edema | No edema | Pitting edema — grade 1+ (2mm) to 4+ (8mm). Note location (bilateral = systemic, unilateral = local) |
| Skin color/temperature | Warm, pink, dry | Pallor, cyanosis, mottling, diaphoresis, cool extremities |
Respiratory
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| Respiratory rate & pattern | 12–20 breaths/min, regular, unlabored | Tachypnea, bradypnea, Cheyne-Stokes, Kussmaul, apnea |
| Breath sounds | Clear to auscultation bilaterally in all lobes | Crackles (fluid), wheezes (bronchospasm), rhonchi (secretions), absent (pneumothorax/effusion) |
| Chest expansion | Symmetric bilateral expansion | Asymmetric — consider pneumothorax, splinting, atelectasis |
| Oxygen saturation | SpO₂ ≥ 95% on room air | < 95% — assess for respiratory distress, notify provider if < 90% |
| Use of accessory muscles | None | Nasal flaring, intercostal retractions, tripod positioning — indicates respiratory distress |
Gastrointestinal & Genitourinary
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| Bowel sounds | 5–30 sounds/minute in all 4 quadrants | Hypoactive (< 5/min — ileus, post-op), hyperactive (> 30/min — diarrhea, obstruction early) |
| Abdomen inspection | Flat or rounded, no distension, no visible pulsations | Distension, visible peristalsis, pulsating mass (AAA) |
| Palpation | Soft, non-tender, no masses | Rigidity (peritonitis), guarding, rebound tenderness, organomegaly |
| Urine output | ≥ 30 mL/hr (0.5 mL/kg/hr) | < 30 mL/hr — assess fluid status, notify provider. Oliguria = < 400 mL/day |
Musculoskeletal & Integumentary
| Assessment | Normal Findings | Abnormal / Action Required |
|---|---|---|
| Range of motion | Full active ROM in all joints | Limited ROM, pain with movement, crepitus — document affected joints |
| Muscle strength | 5/5 bilaterally | Grade 0 (no contraction) to 4/5 (movement against some resistance) |
| Skin integrity | Intact, warm, dry, good turgor | Wounds, pressure injuries (stage I–IV), rashes, lesions — use ABCDE for skin lesions |
| Pressure injury risk | Braden Scale ≥ 19 (low risk) | Braden ≤ 18 — implement prevention protocol (repositioning, pressure-relieving surfaces) |
Reporting Abnormal Findings: Use SBAR
When you identify an abnormal finding, communicate it clearly and promptly using SBAR — the standard framework for clinical handoffs and urgent communications.
"Mr. Johnson in room 412 is experiencing acute respiratory distress."
"He is a 68-year-old with COPD admitted yesterday for pneumonia."
"His SpO₂ has dropped to 88%, RR is 28, and he is using accessory muscles."
"I recommend you come evaluate him now. I've already applied supplemental oxygen."
Practice clinical assessment questions
Medical-Surgical Test Banks Available
Practice assessment-based NCLEX questions covering all body systems — with detailed rationales explaining what each finding means clinically.
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