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 fields82
Avg. time to fill out16 min 58 sec
Other nameshead to toe assessment checklist, head to toe assessment, head to toe nursing assessment form, assessment head toe

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

This PDF editor was created to be as clear as it can be. Once you comply with these steps, the procedure for filling out the head to toe nursing assessment form file is going to be simple and easy.

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 toe assessment

Make sure you type in the necessary data in the Assess, lungs Assess, apical, pulse and impulse, PM, I field.

Filling out head toe assessment part 2

Focus on the most essential details of the PERFORMANCE, BEHAVIORS Check, equipment, related, to, the, patient IV, Solution, rate, site Prior, to, leaving, room and COMMENTS field.

Completing head toe assessment stage 3

The field will be the place to put the rights and obligations of either side.

stage 4 to filling out head toe assessment

Finish by reading the following fields and completing them accordingly: Skill, Sheet, Head, to, Toe, AssessmentS, P

Entering details in head 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.

Watch Head Toe Assessment Video Instruction

If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .