Head-to-Toe Assessment Cheat Sheet for Nursing Students

Why Head-to-Toe Assessment Matters

The head-to-toe physical assessment is the most fundamental clinical skill in nursing. It provides the objective data you need for accurate nursing diagnoses, care planning, and detecting changes in patient condition.

General Survey

Before touching the patient, observe:

• Appearance: Age-appropriate, well-nourished, well-groomed?
• Level of consciousness: Alert and oriented x4 (person, place, time, situation)
• Distress: Signs of acute distress, pain, anxiety?
• Mobility: Gait, posture, use of assistive devices?
• Vital signs: HR, BP, RR, Temp, SpO2, Pain level

Head and Face

Inspection

• Skull: Normocephalic (normal size and shape), atraumatic
• Face: Symmetric, no drooping, no lesions
• Hair: Distribution, texture, presence of lice or nits
• Scalp: No lesions, tenderness, or masses

Key Abnormal Findings

• Facial asymmetry (stroke indicator: use FAST screening)
• Moon face (Cushing syndrome)
• Periorbital edema (renal failure, allergies)

Eyes

Assessment

• Vision: Snellen chart or ability to read
• Pupils: PERRLA (Pupils Equal, Round, Reactive to Light and Accommodation)
• Extraocular movements: EOMI (six cardinal positions of gaze)
• Conjunctiva: Pink (pallor suggests anemia)
• Sclera: White (yellow suggests jaundice)

Ears

• External: No lesions, drainage, or deformity
• Hearing: Responds to normal conversation, whisper test
• Tympanic membrane: Pearly gray (if visualized with otoscope)

Nose and Sinuses

• Patency: Air flow through both nares
• Mucosa: Pink, moist, no polyps
• Septum: Midline, no deviation
• Drainage: Note color, amount, consistency

Mouth and Throat

• Lips: Pink, moist, no lesions
• Oral mucosa: Pink, moist, intact
• Teeth: Condition, dentures, missing teeth
• Tongue: Midline, no fasciculations
• Throat: No erythema, exudate, or swelling
• Gag reflex: Present (important before feeding)

Neck

• Range of motion: Full, no pain
• Trachea: Midline
• Thyroid: Not enlarged or tender
• Lymph nodes: Not palpable or tender
• Jugular vein distension (JVD): Assess at 45 degrees (elevated in heart failure)
• Carotid pulses: Equal bilaterally, no bruits

Chest and Lungs

Inspection

• Chest shape symmetric, AP diameter normal (1:2 ratio)
• Respiratory pattern regular, unlabored
• No accessory muscle use

Auscultation

• Anterior and posterior: Compare bilaterally
• Normal sounds: Vesicular (peripheral), bronchovesicular (main bronchi), bronchial (trachea)
• Adventitious sounds: Crackles, wheezes, rhonchi, stridor, pleural friction rub

Cardiovascular

Auscultation

• Rate and rhythm: Regular rate and rhythm (RRR)
• Heart sounds: S1, S2 present; note S3 (heart failure), S4 (hypertension), murmurs
• Auscultate at: Aortic, pulmonic, Erb's point, tricuspid, mitral

Peripheral

• Pulses: Radial, dorsalis pedis, posterior tibial (rate 0-4+ scale)
• Capillary refill: < 3 seconds
• Edema: Grade 1+ to 4+ (1+ = 2mm, 4+ = 8mm)
• Skin color and temperature of extremities

Abdomen

Order: Inspection, Auscultation, Percussion, Palpation

(Always auscultate BEFORE palpation to avoid altering bowel sounds)

• Inspection: Contour (flat, rounded, distended), scars, lesions
• Auscultation: Bowel sounds in all 4 quadrants (5-30/min is normal)
• Palpation: Tenderness, masses, organ enlargement
• Special: Rebound tenderness (peritonitis), Murphy's sign (cholecystitis)

Musculoskeletal

• Strength: Equal bilaterally, grade 0-5 scale
• Range of motion: Full, no crepitus
• Gait: Steady, balanced
• Joints: No swelling, redness, or deformity

Neurological

• Orientation: Person, place, time, situation (A&Ox4)
• Cranial nerves: CN I-XII (as applicable)
• Sensation: Light touch, sharp/dull discrimination
• Reflexes: Deep tendon reflexes 2+ (normal)
• Coordination: Finger-to-nose, heel-to-shin
• Glasgow Coma Scale: Eye (4), Verbal (5), Motor (6) = 15 normal

Skin (Integumentary)

• Color: Appropriate for ethnicity, no pallor, cyanosis, or jaundice
• Turgor: Returns in < 2 seconds (dehydration indicator)
• Moisture: Dry, moist, or diaphoretic
• Temperature: Warm, cool, or hot
• Integrity: Intact, wounds, pressure injuries (use Braden Scale)

Documentation Template

"Patient is a [age]-year-old [sex] who is alert and oriented x4, in no acute distress. Head normocephalic and atraumatic. PERRLA, EOMI. Oral mucosa pink and moist. Neck supple, trachea midline, no JVD. Lungs clear to auscultation bilaterally. Heart RRR, S1/S2 present, no murmurs. Abdomen soft, non-tender, non-distended, bowel sounds active in all quadrants. Extremities warm, pulses 2+ bilaterally, no edema. Skin warm, dry, intact."

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