The Order of a Head-to-Toe Assessment
General Status
Vital signs
Heart rate
Blood pressure Assess pain using the appropriate pain scale for the patient
Temperature
Pulse oximetry
Respiratory rate
Pain
Check for size, shape, symmetry, lesions, trauma
Head, Ears, Eyes, Nose, Throat (HEENT)
Check for thickening, hardness, and tenderness
Observe for masses, webbing, and skinfolds
Observe head tilt
Inspect skull and scalp
Inspect facial features
Palpate head and scalp
Auscultate temporal arteries if appropriate
Observe the color of lips and moistness
Inspect teeth and gums
Assess buccal mucosa and palate
Examine Tongue
Examine at uvula
Examine tonsils
Palpate nose and assess symmetry
Check Septum and inside nostrils
Verify patency of nares
Check patient’s sense of smell
Palpate sinuses
Assess patient hearing with whisper test
1
Tuning Fork test (Weber’s test, Rinne test)
Look inside ear
Assess ear discharge and tympanic membrane
Check conjunctive and sclera
Assess eye symmetry
PERRLA
Check vision with Snellen Chart
Check six cardinal positions of the gaze
2
Neck
Palpate lymph nodes
o Parotid and retropharyngeal (tonsillar)
o Submandibular
o Submental
o Sublingual (facial)
o Superficial anterior Cervical Check for symmetry, tenderness, shape
o Superficial posterior cervical Check thyroid for size, shape, configuration, tenderness, nodules
o Preauricular and postauricular
o Sternocleidomastoid
o Occipital
o Supraclavicular
Observe and palpate trachea and neck
Check for Jugular Venous Distention
Check neck range of motion
Check shoulder shrug with resistance
3
Respiratory
Inspect the chest
Observe chest for size, shape, symmetry, color, superficial venous
Perform direct and indirect percussion on the chest
patterns, and prominence of ribs
Listen to lung sounds front and back
Evaluate respirations for rate and rhythm
Assess respiratory expansion level
Palpate for thoracic expansion, tactile fremitus
Ask about coughing
Listen for intensity, pitch, duration, and quality of breath sounds
Palpate thorax
Cardiac
Assess for murmurs
Palpate the carotid and temporal pulses bilaterally Listen for heart rate, rhythm, S1 and S2
Auscultate the five areas of the heart
Inspect the precordium
Abdomen Check for skin characteristics, venous patterns, symmetry, surface
motion
Inspect abdomen Check for masses, hernia, separation of the muscles
Listen to 4 quadrants of the abdomen for bowel sounds
Palpate 4 quadrants of the abdomen for pain/tenderness Listen for bruits
Percuss the 4 quadrants of the abdomen Check for tone, liver borders
Ask about problems with bowel or bladder
4
Pulses
Palpate pulses in arms/legs/feet including,
o Brachial (in infants) Ensure pulse are palpable and present
o Radial
o Femoral
o Posterior tibial
o Dorsalis pedi
Extremities
Assess range of motion and strength in arms/legs/ankles Check for muscle tone, warmth, tenderness, swelling, and crepitus
Assess sharp and dull sensation on arms/legs Check for alignment, size, deformities, contour and symmetry
Check capillary refill on fingernails/toenails
Palpate each joint in the hand and write
Skin
Check skin turgor Check for moisture, temperature, texture, turgor, elasticity
Check for lesions, abrasions, rashes Check for color, distribution, density
Check for tenderness, lumps, lesions Identify pigmentation, length, redness, swelling, pain, growths
Check if the patient is pale, clammy, dry, cold, hot, flushed
Gait: posture, rhythm, sequence of stride and arm movements
Neurological
Check for superficial touch and superficial pain response
Test cranial nerves I through XII
Evaluate balance using the Romberg test
Evaluate coordination and fine motor skills
Test primary sensory responses
Oriented x3
Assess gait
5
Assess superficial and deep tendon reflexes
Check the Glasgow Coma Scale score
