The head-to-toe is the single skill nursing school spends the most time on and bedside nursing rewards the least — until you have a critical change and a thorough baseline matters more than anything. Every nurse I've ever oriented does a sloppy head-to-toe in their first six months. This template forces the structure.
Order of the assessment
Standard order: general appearance → vitals → neurological → HEENT (head/eyes/ears/nose/throat) → cardiac → respiratory → abdominal/GI → genitourinary → musculoskeletal → integumentary (skin) → psychosocial. Some texts swap neuro and HEENT; some include vitals as a separate section. Use whatever order your facility's EHR follows so your documentation flows.
General survey and vital signs
The assessment starts at the doorway, before you touch the patient. General appearance: apparent age versus stated age, level of distress, position of comfort (tripoding, guarding, curled on one side), hygiene, and whether the room matches the story (untouched meal tray, empty urinal, full emesis basin). Vital signs: a full set with the oxygen device and flow rate written next to the SpO2. Pain: score, location, quality, and what the patient says is tolerable, then a reassessment after every intervention.
| Vital sign | Typical adult range | Worth a second look |
|---|---|---|
| Temperature | 36.5–37.5 °C (97.7–99.5 °F) | New fever, or a low temp in an older adult with other signs of infection |
| Heart rate | 60–100 bpm | A rising trend from the patient's own baseline, even inside the range |
| Respiratory rate | 12–20 breaths/min | Above 20, counted for a full 30 to 60 seconds, not estimated |
| Blood pressure | Below 120/80 mmHg | Drop from baseline, narrowing pulse pressure, orthostatic change |
| SpO2 | 95–100% on room air | Needing more oxygen to hold the same number. Some COPD patients have an ordered target of 88–92% |
These are general adult reference ranges. Children, pregnant patients, and anyone with an ordered parameter follow different numbers, and your facility's early-warning score thresholds take precedence at the bedside.
Neurological
Mental status: alert and oriented to person, place, time, situation (A&O x4). Cranial nerves: grossly intact (or document specific deficits). Motor: moves all extremities equal strength bilaterally (5/5). Sensory: grossly intact to light touch. Speech: clear and appropriate. Pupils: PERRLA (pupils equal, round, reactive to light, accommodation). Document any deviations precisely (e.g., 'left arm 4/5 strength, right arm 5/5').
HEENT (head, eyes, ears, nose, throat)
Head: normocephalic, symmetric face, no lesions or signs of trauma; note facial droop and when it started. Eyes: sclera white, conjunctiva pink, no drainage; glasses or contacts noted. Ears: hears normal conversation, hearing aids in and working, no drainage. Nose: patent, no drainage; check skin under nasal cannula tubing and around any NG tube for pressure injury. Mouth and throat: mucous membranes pink and moist, dentition or dentures noted, swallows without coughing or pocketing food. Red flags: new facial asymmetry, unequal or fixed pupils, dry cracked mucosa with poor intake, coughing with thin liquids (hold oral intake and request a swallow screen per policy), stridor or drooling.
Cardiac
Heart sounds: S1 and S2 audible, regular rate and rhythm, no murmurs, gallops, or rubs auscultated. Pulses: radial and pedal pulses 2+ bilaterally. Capillary refill: brisk (<3 seconds). Edema: none, or describe location, pitting grade (1+ to 4+), and bilateral vs unilateral. Telemetry: if monitored, note rhythm and rate. Red flags: new murmur, new edema, asymmetric pulses, prolonged capillary refill.
Respiratory
Effort: unlabored, no use of accessory muscles. Rate and depth: within normal range, even and unlabored. Lung sounds: clear to auscultation bilaterally in all fields (anterior, lateral, posterior). Cough: denies cough, or document non-productive vs productive (color of sputum). SpO2: document on room air or current oxygen delivery. Red flags: increased work of breathing, accessory muscle use, adventitious sounds (crackles, wheezes, stridor), decreasing SpO2.
Abdominal/GI
Inspection: abdomen flat (or soft, distended, etc.), no scars unless documented. Auscultation: bowel sounds active in all four quadrants (auscultate BEFORE palpating). Palpation: soft, non-tender, non-distended. Last BM: document date/time and consistency. Diet tolerance: tolerating diet without nausea/vomiting. Red flags: rigid or boardlike abdomen, hyperactive or absent bowel sounds, rebound tenderness, distention with vomiting.
Genitourinary
Output: urinating clear yellow urine without difficulty (or document Foley with rate, color, clarity). Frequency: document any urgency, frequency, dysuria, or hematuria. Catheter: if present, note insertion date, indication, securement, and patency. Red flags: oliguria (<30 mL/hr), anuria, hematuria, foul-smelling urine.
Musculoskeletal & Integumentary
MSK: moves all extremities, no joint deformity, no swelling. Skin: warm, dry, intact, color appropriate for ethnicity, no rashes or lesions unless documented. Pressure injury risk: document Braden score and any existing pressure injuries with stage, location, size, and treatment. Wounds: document location, size (length x width x depth in cm), drainage character, surrounding skin, and dressing. Red flags: new pressure injuries, dehiscence, signs of infection (erythema, warmth, purulent drainage).
Psychosocial, pain, and safety
Mood and affect: calm, cooperative, affect congruent with mood; or describe what you saw (tearful, flat, restless, pulling at lines). Coping and support: who is at the bedside, who the patient calls, what worries them about discharge. Screening: complete the suicide or safety screen your facility requires on admission and when the picture changes, and escalate a positive screen the same shift. Safety: bed low and locked, call light within reach, alarms on per fall-risk score, allergy and ID bands verified against the MAR. Red flags: new confusion or agitation (screen for delirium before assuming it is behavioral), statements about self-harm, a patient who suddenly stops asking questions.
Sample head-to-toe documentation note
This is what a complete narrative looks like for a stable adult med-surg patient. Use it as a pattern, then change every line to what you actually found. A copied normal note is the blanket charting described below.
An abnormal finding gets the same treatment: what you saw, where, how much, compared to when, and who you told. "Crackles R base, new since 0400. SpO2 91% RA, was 95%. HOB raised, IS encouraged, Dr. notified at 0815, order received for chest X-ray" is a defensible note. "Lungs diminished, will monitor" is not.
How to actually do a head-to-toe in real clinical time
The textbook head-to-toe assessment takes 25–30 minutes if you do it linearly. Real bedside practice is closer to 6–10 minutes for an experienced nurse, and the secret is integrating systems rather than going system by system. While you check the IV pump and look at the lines, you are also looking at hand grip, capillary refill, pedal pulse on the side closest to the IV, and skin color. While you place the stethoscope for heart sounds, you are observing chest rise, accessory muscle use, JVD, and any visible scars. While you palpate the abdomen, you are watching facial expression for pain and listening for verbal responses (which screens cognition). The trick to fast assessment is overlap: every body region you touch yields three or four data points if you train yourself to look for them.
Documentation should match what you actually assessed. The biggest legal trap is "blanket charting" — the SmartPhrase that auto-populates "all systems within normal limits, patient denies pain, ambulating ad lib" without the nurse having actually verified those things. If a patient deteriorates and the chart shows the nurse documented a normal assessment that is incompatible with the deterioration, the chart becomes evidence against the nurse. Always edit the SmartPhrase to reflect what you actually found. Document specifics where they exist (left lung base diminished, 2+ pitting edema bilaterally to the knee), and document genuine negative findings explicitly ("no JVD, no peripheral edema").
Trending an assessment over a shift
The first head-to-toe of the shift is the baseline; everything after is a comparison to that baseline. Subsequent rounds — typically q4h on med-surg, q2h on telemetry, q1h on ICU — should be focused reassessments that explicitly compare the patient to the morning baseline. "Lung sounds unchanged from baseline, still diminished L base," "edema increased from 2+ to 3+ in past 4 hours," "patient now disoriented to time, was A&Ox4 at 0700." Trending is what catches subtle deterioration. A patient does not usually go from "fine" to "code blue" in 60 seconds; they go from "fine" to "slightly off" to "noticeably worse" over hours, and the nurse who documents trends rather than only acute findings is the one who catches that progression early.
Adjusting the head-to-toe for older adults and children
Older adults: get a cognitive baseline from family or the facility on day one, because "confused" means nothing without knowing what normal was. Skin is thinner and tears with tape; check heels, sacrum, and under devices every shift. Infection often presents as new confusion, falls, or poor intake rather than fever. Count medications and look for orthostatic changes before the first time the patient stands. In long-term care, the head-to-toe feeds the MDS, so what you chart on admission shapes the care plan for months.
Children: the order changes. Observe and count respirations before the child is disturbed, save the ears, mouth, and anything uncomfortable for last, and let the caregiver hold the child. Vital sign ranges vary by age, so use your unit's age-banded reference or PEWS rather than adult numbers. Weight in kilograms is part of the assessment, since dosing depends on it.
The role of the head-to-toe in early-warning scoring
Most hospitals now use an early-warning score (NEWS2, MEWS, PEWS for pediatrics) integrated into the EHR. These scores combine vital signs, mental status, and oxygen requirement to flag patients at risk for deterioration. The score is only as good as the data — and the data is your assessment. A patient who is "alert" but is now slow to answer questions, who is sat-ing 96% but on 4L NC instead of room air, who has a heart rate of 112 instead of the 84 they were running yesterday, will have a quietly rising NEWS2 score. The nurse who documents A&Ox4 because the patient eventually answered, who logs the same SpO2 without noting the increased oxygen, who marks "afebrile, normotensive" without noting the new tachycardia, suppresses the score. Honest assessment documentation is the single most reliable input to safe-rapid-response systems. When in doubt, document what you saw, not what the SmartPhrase suggests.
Frequently asked
What is included in a head-to-toe assessment checklist?
A complete head-to-toe checklist covers ten areas: general survey and vital signs, neurological, HEENT, cardiac, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin and lines, and psychosocial and safety. Each area lists what to inspect, auscultate, or palpate, what normal looks like, and which findings to escalate. The printable checklist on this page has 49 checks across those ten areas.
What order do you do a head-to-toe assessment in?
Start with a general survey from the doorway and a full set of vital signs, then assess neuro, HEENT, cardiac, respiratory, abdomen, genitourinary, musculoskeletal, skin, and psychosocial status. On the abdomen, auscultate before you palpate. With young children, count respirations first while they are calm and save the ears and mouth for last.
What are normal adult vital signs for a head-to-toe assessment?
Typical adult reference ranges are temperature 36.5 to 37.5 °C (97.7 to 99.5 °F), heart rate 60 to 100 bpm, respiratory rate 12 to 20 breaths per minute, blood pressure below 120/80 mmHg, and SpO2 95 to 100% on room air. A change from the patient's own baseline matters more than a single number, and ordered parameters or your facility's early-warning score take precedence.
How long should a head-to-toe assessment take?
An experienced nurse can do a focused head-to-toe in 5-10 minutes. New grads typically take 15-25 minutes. The first assessment of the shift should be more thorough; subsequent rounds focus on changes from baseline.
Do I need to assess every system every shift?
Yes — most facilities require a complete head-to-toe at least once per shift, plus focused reassessments after interventions or status changes. ICU and step-down often require q4h or q2h focused assessments. Check your facility's policy.
What's a focused assessment vs head-to-toe?
A focused assessment targets the system most relevant to the patient's complaint or condition (e.g., respiratory focused on a COPD exacerbation patient). Head-to-toe is comprehensive across all systems. Use focused for routine reassessment; use head-to-toe for admission, transfer, and beginning-of-shift baselines.
Should I document negative findings?
Yes. 'Skin warm and dry, no rashes' tells the next nurse that you actually looked. 'No abnormalities' is sloppy and legally weak — it doesn't prove you assessed the system. Document specifics, even when they're normal.