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Head To Toe Assessment Guide NUR3805 Nursing Florida University

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John Marsh
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Head to Toe Nursing Assessment Guide Florida International University Professional Nursing I (NUR 3805)

Head to Toe Assessment

 Perform Hand Hygiene and Provide Privacy to patient
 PRESENT YOURSELF
 -Hello, my name is Randy Chavez and I need to perform a head to
toe assessment on you. Is that ok with you?
 LOOK AT PATIENT’S ARM BAND
– (This will help you to have the right patient)-
 -Ask Patient all personal information in the Band to help you check
their NEUROSTATUS
 -Can you tell me where we at?
 -Can you tell me what we are doing today?
 -Can you tell me who is the President of the U.S?
(If Patient responds to all questions correctly, you can say that patient is
ORIENTED AND ALERT x 3)
 VITAL SIGNS
-Heart rate (60-100 bpm)
-Blood Pressure (119/79)
-Temperature (98.6)
-Oxygen Saturation (75-100 mm of mercury)
-Respiratory Rate (12-20 Breaths per minute)
-Patient Pain Rate
 Ask Patient: -Are you having any pain on a scale of 0-10,
zero for the less pain and 10 for the worse pain you have
ever had?
 COLLECT HEIGHT, WEIGHT, BMI
BMI: -less than 18.5 (underweight)
-more than 30 (obese)
WHY WE ASK ALL THESE QUESTIONS?…
-Why are we asking all these
questions and taking vital signs to
the patient?
A/ The meaning of all done above is
to collect all information from the
patient and check for:
-Patient’s Emotional Status: (are
they calmed, agitated, drowsy?), in
fact just to see what’s going on
with the patients.
-To check if they look their stated
age.
-To check if the skin color matches
their ethnicity?
-To check if they understand all the
questions and see if they can hear
well, or if is a delay on their
responses.
-To notice while talking any masses,
lesions, amputations, skin sweaty.
-To check if their hygiene is good?

HEAD TO TOE ASSESSMENT GUIDE 2

-To check if their posture is good? -To check for any abnormal smell.
Then move on to HEAD
 First, Inspect the head.
 Look for Skin Color
o If is nice and pink?
 Check that head is in size with the body
 Check for any abnormal or twitching of the face that Patient cannot
control by himself or does involuntary
 Check that face is symmetrical (like bell’s palsy and people with
Stroke)
 Look for Eyes on the Same Level
 Look at facial Expressions and check CRANIAL NERVE # VII (7) FACIAL,
performing a facial nerve check.

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Head To Toe Assessment Guide NUR3805 Nursing Florida University

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