FAQ: How To Document Head To Toe Assessment For Nursing School Check Off?

How do I document head assessment?

Documenting a normal exam of the head, eyes, ears, nose and throat should look something along the lines of the following:

  1. Head – The head is normocephalic and atraumatic without tenderness, visible or palpable masses, depressions, or scarring.
  2. Eyes – Visual acuity is intact.

When do you do a full head-to-toe assessment?

A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each shift, and when it is determined to be necessary by the patient’s hemodynamic status and the context.

What is the correct order for physical assessment?

Order of physical assessment: Inspect, palpate, percuss, auscultate. EXCEPT for assessing the abdomen: Inspect, auscultate, percuss, palpate (to avoid altering bowel sounds).

What are the 4 types of nursing assessments?

WHEN YOU PERFORM a physical assessment, you’ll use four techniques: inspection, palpation, percussion, and auscultation.

Why do we do head to toe assessment?

The objective of a head-to-toe assessment checklist is to gain insight into the patient’s current health status, health needs, and their goals for health outcomes.

You might be interested:  What Motivated You To Pursue Nursing School, And To Pursue It At This Time In Your Life?

What type of assessment is performed on admission?

Admission assessment: Comprehensive nursing assessment including patient history, general appearance, physical examination and vital signs. Shift Assessment: Concise nursing assessment completed at the commencement of each shift or if patient condition changes at any other time.

How do you document a heart assessment?

Documentation of a basic, normal heart exam should look something along the lines of the following: The external chest is normal in appearance without lifts, heaves, or thrills. PMI is not visible and is palpated in the 5th intercostal space at the midclavicular line. Heart rate and rhythm are normal.

What are the five steps of patient assessment?

Terms in this set (23)

  • General Impression.
  • Level of Consciousness.
  • Open Airway [A]
  • Check Breathing [B]
  • Check Pulse [C] *check skin.
  • Check Major Bleeding.

What are the steps of nursing assessment?

These are assessment, diagnosis, planning, implementation, and evaluation. Assessment is the first step and involves critical thinking skills and data collection; subjective and objective.

What is included in a nursing assessment?

The typical nursing assessment in the clinical setting will be the collection of data about the following:

  • present complaint and nature of symptoms.
  • onset of symptoms.
  • severity of symptoms.
  • classifying symptoms as acute or chronic.
  • health history.
  • family history.
  • social history.
  • current medical and/or nursing management.

How do you do a quick physical assessment?


  1. Head & Sinuses -Inspect and palpate head–for signs of trauma, scars, tenderness or abnormalities.
  2. Eyes – 1) Inspect the sclerae and conjunctiva for color and irritation.
  3. Ears – 1) Inspect the external ear for discharge, skin changes, or masses.
You might be interested:  Question: How To Study For Med Surg In Nursing School?

What are the steps to complete a physical assessment?

The framework presented here consists of the following sequence of steps: identifying the purpose of the assessment; taking a health history; choosing a comprehensive or focused approach; and examining the patient using the sequence of inspection, palpation, percussion and auscultation.

Leave a Reply

Your email address will not be published. Required fields are marked *