Head Toe Assessment PDF Details

Are you looking for a way to more effectively assess your patients? If so, you may want to consider using the Head Toe Assessment Form. This form can help you to better identify any problems that your patients may be experiencing. By using this form, you can ensure that you are providing the best possible care for your patients.

If you'd like to first learn how much time you will need to prepare the head toe assessment and what number of pages it's got, here is some detailed information that might be useful.

Form NameHead Toe Assessment
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameshead to toe assessment printable, head to toe nursing assessment form, head to toe assessment, head to toe assessment checklist pdf

Form Preview Example

Head to Toe Assessment

Student Name:




Student Signature:




Evaluator Signature: 1st attempt














Evaluator Signature: 2nd attempt













Evaluator Signature: 3rd attempt












** Critical Behaviors that need to be stated or done in

to pass theskill.

















1.Gather equipment needed for assessment


b.Appropriate sized blood pressure cuff

c.Pulse Oximeter




2.Upon entering the patient’s room:

a.**Perform hand hygiene

b.Identify self

c.**Identify patient using 2 forms of ID (name and date ofbirth)

d.**Verify patient allergies

e.Assure privacy

f.**Explain what is about to occur

g.Allow for patient questions

h.Raise bed to comfortable working height

i.Don gloves


3.**Assess level of consciousness and orientation to person, time and place.

4.Perform assessments for pain, pulse oximetry, blood pressure, pulse, respiratory rate, and temperature.

5.Assess head and PERRLA (Pupils Equal, Round, React to Light, and Accommodation)

a.Observe for any gross abnormalities of the head and face.

6.**Throughout assessment observe and note condition of hair, skin and nails.

7.** Assess and compare bilateral upper extremities for:

a.Hand grasps for equality and strength

b.Temperature and color

c.Radial pulses

d.Capillary refill


8.**Assess apical pulse.

a.Auscultate heart sounds at left mid-clavicular line fifth intercostal space. Point of maximal impulse (PMI).

b.Listen for one full minute, noting rate and regularity.

9.**Assess lungs.

a.Listen and observe rise and fall of chest and count respirations.

b.Auscultate breath sounds.

1.Assess anterior chest in 4 sites and 2 lateral sites.

2.Assess posterior chest in 4 sites and 2 lateralsites.

**Critical Behaviors that need to be stated or done in order to pass the skill.

Skill Sheet Head to Toe Assessment SP2022



10.**Assess abdomen (Inspection, Auscultation, Palpation)

a.Auscultate for bowel sounds in all four quadrants

b.Palpate abdomen for firmness, tenderness, and lower abdomen for bladderdistention.

11.**Assess and compare bilateral lower extremities for

a.Movement and strength

b.Temperature and color

c.Dorsalis pedis and posterior tibial pulses

d.Capillary refill


12.Assess posterior lung sounds (if not done previously) and skin

13.**Check equipment related to the patient

a.IV? Solution, rate, site.

b.O2? Setting/type

c.Drains (including urinary catheter).

14.Survey the environment for safety concerns.

a.**Reposition patient for comfort and safety

15.Prior to leaving room

a.**Lower bed

b.**Raise appropriate bed rails

c.**Place call light and patient belongings within reach

d.**Perform hand hygiene

e.Gather and remove equipment


16. **Document assessment per facility policy

*S = Satisfactory, ^U = Unsatisfactory

**Critical Behaviors that need to be stated or done in order to pass the skill.

17. Write a sample nursing note:

Skill Sheet Head to Toe Assessment SP2022

How to Edit Head Toe Assessment Online for Free

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Step 1: Initially, choose the orange button "Get Form Now".

Step 2: Now you are on the document editing page. You can edit, add information, highlight particular words or phrases, place crosses or checks, and insert images.

Create the next parts to complete the document:

example of gaps in head to toe assessment

Make sure you type in the necessary data in the Upon entering the patients room a, Assessment Assess level of, Perform assessments for pain, a Observe for any gross, Throughout assessment observe and, Assess and compare bilateral, a Hand grasps for equality and, Assess apical pulse, a Auscultate heart sounds at left, impulse PMI, b Listen for one full minute, Assess lungs, a Listen and observe rise and fall, and Assess anterior chest in sites field.

Filling out head to toe assessment part 2

Focus on the most essential details of the PERFORMANCE BEHAVIORS, COMMENTS, Assess abdomen Inspection, Assess and compare bilateral, a Movement and strength b, Assess posterior lung sounds if, Check equipment related to the, IV Solution rate site, a b O Settingtype c Drains, Reposition patient for comfort and, and Prior to leaving room a Lower bed field.

Completing head to toe assessment stage 3

The Prior to leaving room a Lower bed, Evaluation Document assessment, and S Satisfactory U Unsatisfactory field will be the place to put the rights and obligations of either side.

stage 4 to filling out head to toe assessment

Finish by reading the following fields and completing them accordingly: Skill Sheet Head to Toe Assessment.

Entering details in head to toe assessment part 5

Step 3: Press the button "Done". The PDF file is available to be exported. You can download it to your computer or send it by email.

Step 4: Ensure you keep away from future worries by generating minimally two copies of the document.

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