Head-to-Toe Nursing Assessment: A Step-by-Step Checklist (With Normal and Abnormal Findings)

A head-to-toe assessment is a systematic physical examination that nurses perform on admission, at the start of a shift, and whenever a patient’s condition changes. It gives you a baseline, helps you catch problems early, and is a core skill tested in nursing OSCEs. Done well, a focused head-to-toe takes 10–15 minutes.

Before you start

• Introduce yourself, confirm identity, explain and gain consent.
• Hand hygiene; ensure privacy and good light.
• Gather equipment: stethoscope, BP cuff, thermometer, pulse oximeter, penlight, watch, gloves.
• Use the four techniques: inspection, palpation, percussion, auscultation (for the abdomen: inspect, auscultate, then percuss and palpate).

1. General survey and vital signs

Appearance, distress, posture, hygiene, odours, mood, speech. Record temperature, pulse, respiratory rate, BP, SpO₂, pain score and weight. See our normal vital signs guide.

2. Neurological

• Level of consciousness: ACVPU or GCS; orientation to person, place and time.
• Pupils: size, equality, reaction to light (PERRLA: pupils equal, round, reactive to light and accommodation).
• Speech, facial symmetry, grip strength and limb movement on both sides.
• Abnormal: new confusion, unequal pupils, one-sided weakness, slurred speech.

3. Head, eyes, ears, nose and throat

• Scalp and face: lesions, swelling, symmetry.
• Eyes: conjunctiva (pallor suggests anaemia), sclera (yellow suggests jaundice), discharge.
• Mouth: moist or dry mucosa, oral thrush, ulcers, dentition, dentures.
• Neck: lymph nodes, jugular venous distension, trachea midline.

4. Respiratory

• Inspect: rate, rhythm, depth, effort, use of accessory muscles, chest symmetry, cough and sputum.
• Auscultate front and back, comparing sides from top to bottom.
• Normal: clear vesicular breath sounds bilaterally.
• Abnormal: crackles (fluid: pneumonia, heart failure), wheeze (narrowed airways: asthma, COPD), stridor (upper airway obstruction: emergency), absent sounds (collapse, effusion, pneumothorax).

5. Cardiovascular

• Apical pulse (one full minute if irregular); heart sounds S1 and S2; murmurs.
• Capillary refill: normally 2 seconds or less.
• Peripheral pulses (radial, pedal), skin temperature and colour of extremities.
• Oedema: press for 5 seconds over the shin or ankle; grade pitting.
• Abnormal: irregular pulse, prolonged capillary refill, cold peripheries, new oedema.

6. Abdomen and gastrointestinal

• Inspect: shape, distension, scars, stomas, drains.
• Auscultate bowel sounds in all four quadrants before palpating.
• Palpate gently for tenderness, guarding and masses, starting away from any painful area.
• Ask about appetite, nausea, vomiting, last bowel movement, stool character.
• Abnormal: rigid abdomen, rebound tenderness, absent bowel sounds, black or bloody stools.

7. Genitourinary

• Urine output, colour, odour; pain or burning; frequency; continence.
• Catheter: indication, patency, drainage, date inserted. See our catheter care guide.
• Palpate for a distended bladder if retention is suspected.

8. Musculoskeletal

• Range of movement, strength, gait (if safe), joint swelling or deformity.
• Mobility aids; falls risk assessment.

9. Skin (integumentary)

• Colour, temperature, moisture, turgor.
• Pressure areas: sacrum, heels, hips, elbows, ears, back of head; under devices. Use a risk tool such as the Braden Scale.
• Wounds, bruises, rashes, IV sites (phlebitis score).
• On darker skin, look for changes in colour, warmth and texture rather than redness alone.
• Unexplained bruises or injuries in a child, older adult or vulnerable person: follow safeguarding procedures.

10. Psychosocial

• Mood, anxiety, sleep, coping, support at home.
• Cultural, religious and language needs.
• Ask directly if there are concerns about self-harm. See our guide to asking about suicide.

After the assessment

• Act on abnormal findings and escalate using SBAR.
• Document clearly, by system, highlighting changes from the previous assessment. See our documentation guide.
• Use findings to update the care plan.

Tips for the OSCE

• Talk the examiner through what you are doing and why.
• Keep the patient covered except for the area being examined.
• Check on patient comfort throughout.
• Finish by thanking the patient, washing hands, documenting and stating your next steps.

Educational content based on standard nursing physical assessment practice. Follow your local assessment policy and documentation system.