Learn a complete nursing head-to-toe assessment with a clear assessment order, normal findings, abnormal findings, safety cues, documentation examples, and practice questions.
This guide is built for nursing students, medical assistant students, EMT learners, allied health learners, TEAS learners, and early healthcare professionals who want to understand what to assess, what to notice first, and when a finding may require action.
A head-to-toe assessment is a systematic way to evaluate a patient's overall condition from general appearance through each major body system. It helps nurses and healthcare learners identify normal findings, recognize changes, catch safety concerns, and decide what needs follow-up.
In school, a head-to-toe assessment is often taught as a full sequence. In real clinical care, nurses often combine a full assessment with focused assessment based on the patient's complaint, diagnosis, level of stability, and current risk.
The exact order can vary by program or facility, but a consistent pattern helps you avoid missing important findings. A good assessment should be organized, objective, and patient-centered.
The general survey begins the moment you enter the room. Before touching the patient, observe appearance, breathing effort, positioning, speech, skin color, hygiene, distress level, and safety risks.
Vital signs give objective data about oxygenation, circulation, temperature, and overall stability. Pain assessment gives additional information about comfort, function, and possible underlying problems.
| Vital Sign | Assess | What to Notice |
|---|---|---|
| Temperature | Fever, hypothermia, trends. | Fever may suggest infection; low temperature may be concerning in sepsis, exposure, or frailty. |
| Heart Rate | Rate, rhythm, strength. | Tachycardia, bradycardia, irregular rhythm, sudden changes. |
| Respirations | Rate, depth, work of breathing. | Tachypnea, bradypnea, apnea, shallow breathing, labored breathing. |
| Blood Pressure | High, low, trend, symptoms. | Hypotension with symptoms, severe hypertension, sudden changes. |
| SpO₂ | Oxygen saturation and oxygen device if present. | Low oxygen saturation, respiratory distress, device not connected properly. |
| Pain | Location, severity, quality, onset, radiation, triggers. | Chest pain, sudden severe headache, abdominal pain with rigidity, pain out of proportion. |
Review related MedSkillBuilder resources: Normal Vital Signs Chart, Vital Signs Practice Quiz, and Spot the Problem: Vital Signs Challenge.
A basic neurological assessment checks mental status, orientation, speech, pupil response, strength, sensation, and signs of acute neurologic change. A focused neuro assessment may be needed if the patient has stroke symptoms, head injury, seizure activity, confusion, or altered level of consciousness.
The head and neck portion of the assessment includes symmetry, trauma, vision concerns, hearing concerns, oral mucosa, swallowing, neck mobility, lymph nodes when appropriate, and airway concerns.
| Area | Normal Findings | Abnormal Findings |
|---|---|---|
| Head and Face | Symmetrical face, no obvious trauma, expression appropriate. | Facial droop, swelling, trauma, unequal movement. |
| Eyes | Pupils equal/reactive if assessed, no new vision complaint. | Unequal pupils, sudden vision loss, eye pain, drainage. |
| Ears | Hearing appropriate, no acute drainage or pain. | New hearing loss, drainage, severe ear pain, dizziness. |
| Nose | Nares patent, no acute bleeding or severe congestion. | Nosebleed, obstruction, drainage, trauma. |
| Mouth/Throat | Moist mucosa, able to speak/swallow as expected. | Dry mucosa, choking, difficulty swallowing, swelling, airway concern. |
| Neck | Moves neck as expected, no obvious swelling. | Neck stiffness, swelling, JVD, tracheal deviation, severe pain. |
The respiratory assessment focuses on breathing rate, oxygenation, work of breathing, chest movement, lung sounds, cough, sputum, oxygen delivery device, and signs of respiratory distress.
Related practice: Lung Sounds Quiz, Oxygen Delivery Devices Guide, ABG Practice Quiz, and ABG Normal Values Guide.
Cardiac assessment includes heart rate, rhythm, heart sounds when appropriate, chest pain, peripheral pulses, capillary refill, edema, skin temperature, and signs of poor perfusion.
Related practice: Heart Sounds Quiz, EKG Practice Quiz, EKG Rhythm Cheat Sheet, and How to Read an EKG.
Abdominal assessment focuses on appetite, nausea, vomiting, bowel sounds when required, bowel patterns, distention, tenderness, guarding, and changes in elimination.
Related learning: Digestive System Anatomy Guide.
Genitourinary assessment may include urinary pattern, urine output, color, discomfort, catheter status, intake and output, hydration signs, edema, and kidney-related lab values depending on the patient's condition.
Urination frequency, pain, burning, urgency, retention, incontinence, and changes from baseline.
Urine amount, color, catheter drainage, intake/output, edema, and hydration cues.
BUN, creatinine, GFR, electrolytes, and fluid balance when relevant.
Related resources: Fluid Balance Guide, BUN, Creatinine & GFR Guide, and Electrolyte Imbalance Guide.
Extremity assessment includes strength, range of motion, sensation, pulses, edema, color, temperature, capillary refill, mobility, assistive devices, and fall risk.
| Assessment Area | Normal Finding | Concerning Finding |
|---|---|---|
| Strength | Equal or expected strength bilaterally. | New one-sided weakness or inability to move limb. |
| Sensation | Sensation intact or at baseline. | New numbness, tingling, or loss of sensation. |
| Pulses | Peripheral pulses present. | Absent pulse, cool extremity, severe pain. |
| Edema | No edema or known baseline. | New unilateral swelling, sudden severe swelling, pitting edema with symptoms. |
| Mobility | Ambulates safely or uses assistive device correctly. | Fall risk, dizziness, unsteady gait, new weakness. |
Skin assessment includes color, temperature, moisture, turgor, wounds, pressure injury risk, bruising, rashes, surgical sites, IV sites, tubes, drains, and devices.
Use this checklist as a quick study guide. Your school or facility may require a different order or more detailed steps.
| Step | Check | What to Document |
|---|---|---|
| 1 | General appearance and safety | Alertness, distress, positioning, safety concerns. |
| 2 | Vital signs and pain | Vitals, pain score, oxygen device, abnormal trends. |
| 3 | Neuro and mental status | Orientation, speech, pupils if assessed, strength, changes. |
| 4 | Head and neck | Symmetry, trauma, swallowing, neck findings. |
| 5 | Respiratory | Respiratory effort, lung sounds, cough, SpO₂, oxygen. |
| 6 | Cardiac/circulation | Heart rate/rhythm, pulses, edema, chest pain, perfusion. |
| 7 | Abdomen/GI | Bowel sounds if assessed, tenderness, distention, nausea, bowel pattern. |
| 8 | GU/fluid status | Urine output, catheter, I/O, edema, urinary symptoms. |
| 9 | Extremities/mobility | Strength, pulses, edema, gait, fall risk. |
| 10 | Skin/wounds/lines/drains | Skin integrity, wounds, IV sites, tubes, drains, dressings. |
Good documentation is objective, organized, and specific. Avoid vague charting. Document what you assessed, what you found, what you did, who was notified when needed, and reassessment findings.
Patient alert and oriented, resting in bed, no acute distress noted. Respirations even and unlabored. Lung sounds clear bilaterally. Heart rate regular. Abdomen soft, non-tender. Skin warm and dry. No new edema noted. Call light within reach, bed low, safety measures in place.
Patient reports shortness of breath. Respirations labored with accessory muscle use noted. SpO₂ decreased from baseline. Lung sounds with wheezing noted bilaterally. Provider/appropriate clinician notified per policy. Oxygen/device/interventions documented according to orders and facility policy. Patient reassessed after intervention.
Patient reports pain 7/10 to lower abdomen, sharp, onset this morning, worsens with movement. Abdomen tender to palpation. Provider notified per policy. Medication/intervention administered as ordered. Pain reassessed and documented.
ABCs and urgent problems come before routine head-to-toe order.
Abnormal findings, interventions, notifications, and reassessment are often the most important details.
Compare pupils, grips, pulses, lung sounds, strength, and edema when appropriate.
Fall risk, bed position, call light, lines, drains, oxygen tubing, and alarms matter.
If you intervene, reassess. Pain, oxygenation, vitals, and symptoms need follow-up.
Try answering each question before reading the explanation.
1. You enter a room and the patient is sitting upright, using accessory muscles, and can only speak one-word answers. What should you assess first?
A. Bowel sounds
B. Respiratory status
C. Skin turgor
D. Pedal pulses
2. Which finding is most concerning during a neuro check?
A. Patient reports mild fatigue
B. New one-sided weakness
C. Patient wears glasses
D. Patient asks for water
3. Which assessment finding should be prioritized?
A. Pain 4/10 after walking
B. Temperature 99.1°F
C. Oxygen saturation 82% with shortness of breath
D. Dry skin on elbows
4. During abdominal assessment, what order is commonly taught?
A. Palpate, auscultate, inspect, percuss
B. Inspect, auscultate, percuss, palpate
C. Auscultate, palpate, inspect, percuss
D. Percuss, palpate, inspect, auscultate
5. Which documentation is most objective?
A. Patient looks bad
B. Patient is being dramatic
C. Respirations 28/min, labored, accessory muscle use noted
D. Patient seems weird
6. Which finding may suggest poor peripheral perfusion?
A. Warm pink extremities
B. Strong equal pulses
C. Cool pale extremity with weak pulse
D. Full range of motion
7. Which action is most appropriate after giving pain medication?
A. Never reassess pain
B. Reassess pain according to policy
C. Document before giving the medication
D. Ignore pain if the patient is quiet
8. Which finding during a general survey is most urgent?
A. Patient watching TV
B. Patient reports being hungry
C. Patient is cyanotic and confused
D. Patient has dry lips
9. Which is a safety concern to include in assessment?
A. Call light out of reach
B. Bed in low position
C. Non-skid socks on
D. Clear walkway
10. Which assessment is most connected to medication safety before an antihypertensive?
A. Blood pressure
B. Hair color
C. Eye color
D. Shoe size
Build more nursing judgment with RN Practice Questions, Who Do You See First Challenge, and Medication Administration Rights Guide.
A head-to-toe assessment commonly includes general survey, vital signs, pain, neurological status, head and neck, eyes, ears, nose, mouth, respiratory system, cardiac system, abdomen, genitourinary concerns, extremities, skin, wounds, lines, drains, mobility, and safety.
The nurse should first look for immediate airway, breathing, circulation, safety, and life-threatening concerns. If the patient is unstable, focused assessment and urgent intervention take priority over routine sequence.
Normal respiratory findings may include even and unlabored respirations, symmetrical chest rise, clear or baseline lung sounds, and oxygen saturation appropriate for the patient.
Abnormal findings include new confusion, one-sided weakness, chest pain, severe shortness of breath, low oxygen saturation, absent pulses, severe abdominal pain, new edema, skin breakdown, and abnormal vital signs.
Document objective findings, abnormal assessment details, patient statements when relevant, interventions, notifications, and reassessment. Use your facility's documentation standards.
Timing depends on patient condition, setting, required detail, and whether the assessment is full or focused. Learning assessments may take longer than experienced clinical assessments.
A focused assessment targets a specific problem or body system. For example, shortness of breath requires a respiratory-focused assessment rather than only a routine full sequence.
Use these free tools to strengthen the skills that connect directly to physical assessment.