Clinical skills · Assessment
A head-to-toe assessment is a search for change, not a checklist.
The order matters, but the order isn't the skill. Here is the full head-to-toe sequence nurses use, worked through one patient, showing what to look for at each stop and how the findings fit together.
Most students learn the head-to-toe assessment as a list of things to touch, listen to, and click. Then they finish the list and still can't say what's going on with the patient. A good assessment is organized like the checklist, but it's driven by a question: what has changed, and does it matter right now?
The sequence follows the head-to-toe checklist in the open-access Open RN Nursing Skills textbook. Your program or facility may teach a slightly different order. Follow theirs on graded check-offs and use this guide to understand the reasoning behind each step. The patient below is a fictional teaching case, and the same patient appears in our SOAP note and care plan guides.
01 / The case
Meet the patient.
Mr. D. is 72 years old. He was admitted yesterday with community-acquired pneumonia, and you're assigned to him on day 2. The handoff report says he is "on 2 liters, coughing a lot, didn't eat much dinner." That's all you know when you walk in. Keep three questions in mind for the whole assessment: Is he safe right now? What's different from the last assessment? What is the pneumonia doing to the rest of him?
02 / Before you touch anything
Prepare, then run the primary survey.
Perform hand hygiene, introduce yourself, explain what you're about to do, and confirm the patient's identity with two identifiers. Then, before the detailed exam, take a few seconds for the primary survey: is the airway open, is breathing adequate, is circulation adequate (skin color and moisture), and is the patient responsive and oriented?
If the primary survey shows a threat to airway, breathing, circulation, or level of consciousness, the head-to-toe assessment pauses. Stay with the patient, call for help, and follow your facility's rapid-response process. A complete checklist never outranks an unstable patient.
Mr. D.: He is speaking in full sentences, breathing a little fast, skin warm and slightly flushed, alert and answering appropriately. He isn't in immediate danger, so you continue, but "breathing a little fast" is now a thread you'll follow.
03 / The first look
General survey and the chief concern.
The general survey is what you notice before you pick up a stethoscope: appearance, behavior and mood, mobility and balance, communication, and overall nutrition and fluid status. Then ask about the patient's main concern and any pain, using a structured symptom assessment such as PQRSTU (provoking factors, quality, region and radiation, severity, timing, and understanding).
- Appearance
- Tired, sitting upright in bed, coughing every few minutes
- Mobility
- Says he got dizzy walking to the bathroom last night
- Nutrition & fluids
- Lips dry; dinner tray mostly untouched
- Chief concern
- "It hurts on my right side when I cough." Sharp, 4/10, worse with deep breaths
Three threads are already forming: breathing, hydration, and safety when he moves. The rest of the assessment confirms or rules them out.
04 / Numbers
Vital signs: read them as a set.
Take temperature, pulse, respirations, blood pressure, oxygen saturation, and pain. Then compare them with the previous set and the patient's baseline instead of judging each one alone. Our vital signs guide covers normal ranges and trend reading in depth.
Mr. D.: temperature 38.4 °C (101.1 °F), heart rate 104, respirations 24, blood pressure 128/76, SpO2 90% on 2 L/min nasal cannula, pain 4/10. Taken together, the fever, fast heart rate, and fast breathing fit an ongoing infection. The oxygen saturation on supplemental oxygen is the number to compare against the last set and his prescribed target. If it's trending down, that changes your priorities.
05 / Systems
The body systems, in order, and what each one is asking.
Work from head to toe so nothing gets skipped, but spend your time where the threads lead. Here is the sequence, with the question each system answers for this patient:
Is he thinking clearly?
Level of consciousness, orientation, pupils, movement and sensation. New confusion in an older adult with infection is an important cue.
Head, eyes, ears, neck
Inspect, and check mucous membranes and lymph nodes. Mr. D.'s dry mucous membranes support the hydration thread.
Is he perfusing?
Heart sounds, pulses, capillary refill, and edema. Note whether the fast heart rate is regular.
Where is the problem?
Effort, symmetry, lung sounds in every lobe, cough and sputum, oxygen device. Crackles in the right lower lobe localize the pneumonia. See the focused respiratory guide.
Intake and output
Bowel sounds, tenderness, last bowel movement, urine amount and color. Dark, scant urine supports dehydration.
What could go wrong next?
Skin integrity, pressure areas, IV site, then fall and safety checks before you leave.
Mr. D.'s key system findings: alert and oriented to person, place, time, and situation; crackles in the right lower lobe with diminished sounds at the right base; productive cough with yellow sputum; regular rhythm; dark amber urine; IV site clean; skin intact. He needed help to stand and was unsteady.
06 / Synthesis
Turn findings into a clinical picture.
The assessment isn't finished when the last system is checked. It's finished when you can sum up the patient in a sentence or two and name your priorities. Group related cues together instead of listing them system by system:
Breathing
Fast breathing, SpO2 90% on 2 L, right lower lobe crackles, productive cough, and pleuritic pain point to impaired airway clearance and gas exchange.
Fluids
Fever, poor intake, dry mucous membranes, and dark urine suggest he's at risk of dehydration.
Safety
Dizziness on standing, unsteadiness, age, and acute illness add up to fall risk.
A finding you can't connect to anything is a question to ask, not a box to tick.
Report what has changed or is concerning to the charge nurse or provider, using a structured format such as SBAR. Then document the assessment. Our SOAP note guide writes up Mr. D.'s findings, and the care plan guide turns these three priorities into nursing diagnoses, outcomes, and interventions.
07 / Checklist
Head-to-toe checklist.
Keep going with Mr. D.
Document it, then plan for it.
Practice in simulation
Running a head-to-toe in Shadow Health?
The Tina Jones comprehensive assessment in Shadow Health asks for a complete history and a head-to-toe exam in one encounter. NursingProxy has a study page for that module covering every body system, with documentation and care-plan materials.
See the Tina Jones comprehensive assessment resource Relationship disclosure: NurseCaseLab and NursingProxy are related learning properties. This external resource is optional and isn't required to use this guide. Follow your program's academic integrity policy.Sources & further reading
Check the sequence against the source.
- Ernstmeyer K, Christman E, eds. Nursing Skills (Open RN), Appendix C: Head-to-Toe Assessment Checklist
- Nursing Skills (Open RN), full text, including the general survey and body-system assessment chapters
- Nursing Fundamentals (Open RN), 2.5 Documentation
Mr. D. is a fictional teaching case. This guide is nursing education, not medical advice, and doesn't replace your program's instruction, your clinical instructor, or your facility's policies. Shadow Health is an Elsevier product; NurseCaseLab isn't affiliated with or endorsed by Elsevier.