NR304 Head to Toe Assessment Exercises
Section 1 (Introduction)
Steps
1. Acknowledge Presence
a. Knock Knock, "Hello there"
2. Introduce Yourself
a. "My name is First, Last and I am the Nurse that will be doing your Head to
Toe Assessment as ordered by your doctor."
3. Duration Of Assessment
a. "It will take about 30 minutes to complete"
4. Explain Reason
a. "It is for an overall health and wellness check."
5. Perform Hand Hygiene
a. "I'm going to wash my hands first before we get started"
6. Privacy
a. "Let me draw this curtain for some privacy"
7. Identifiers
a. "Can you please tell me what your first and last name is and your date of
birth?"
i. "Patient states their name is John Doe and date of birth is March 24,
1973"
8. Determine Allergies
a. "Can you tell me if you have any known allergies to medications or foods?"
i. "Patient states there are no allergies"
9. Assess Pain Levels
a. "Do you have any pain? On a scale from 0-10, 0 being no pain at all, 10 being
the worst pain. How would you rate it?”
i. "Patient states there is no pain"
Section 2 (General Appearance) “I will be assessing general appearance”
2. “Patient with no signs of acute distress”
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, 3. “Facial expression is appropriate to the situation”
4. “Mood/Affect is calm and pleasant”
5. “Speech is clear and articulate”
Level of Consciousness “I will be assessing the level of consciousness”
6. Alert- Person “Patient alert/oriented x 2 (Already identified full name/DOB)”
7. Oriented- Place “Where are you Mr. Doe?” “ Patient states that he is in
Chamberlain hospital”
8. Time “What time is it?” “Patient states that it is 11:00am”
9. Situation- “Can you tell me the reason that you’re here?” “Patients states he/she is
here for a wellness exam ordered by his/her doctor”
Section 3 (Vital Signs) (Will not be included on Return Demo but good to practice)
Can state “Vitals were taken earlier and are within normal limits”
10. “Temperature is 98.6”
11. “Pulse is 66 regular 2+ force”
12. “Respiration is 16”
13. “Oxygen saturation at room air is 99%”
14. “BP is 110/70”
Section 4 (Skin and Nails) “I will now move onto the skin and nails”
15. Inspect Skin
a. Color, Lesions, Wounds, Incisions
16. Inspect Nails
a. Color, Shape/Countour
b. Assess capillary refil
17. “Skin color is consistent with ethnicity”
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Section 1 (Introduction)
Steps
1. Acknowledge Presence
a. Knock Knock, "Hello there"
2. Introduce Yourself
a. "My name is First, Last and I am the Nurse that will be doing your Head to
Toe Assessment as ordered by your doctor."
3. Duration Of Assessment
a. "It will take about 30 minutes to complete"
4. Explain Reason
a. "It is for an overall health and wellness check."
5. Perform Hand Hygiene
a. "I'm going to wash my hands first before we get started"
6. Privacy
a. "Let me draw this curtain for some privacy"
7. Identifiers
a. "Can you please tell me what your first and last name is and your date of
birth?"
i. "Patient states their name is John Doe and date of birth is March 24,
1973"
8. Determine Allergies
a. "Can you tell me if you have any known allergies to medications or foods?"
i. "Patient states there are no allergies"
9. Assess Pain Levels
a. "Do you have any pain? On a scale from 0-10, 0 being no pain at all, 10 being
the worst pain. How would you rate it?”
i. "Patient states there is no pain"
Section 2 (General Appearance) “I will be assessing general appearance”
2. “Patient with no signs of acute distress”
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, 3. “Facial expression is appropriate to the situation”
4. “Mood/Affect is calm and pleasant”
5. “Speech is clear and articulate”
Level of Consciousness “I will be assessing the level of consciousness”
6. Alert- Person “Patient alert/oriented x 2 (Already identified full name/DOB)”
7. Oriented- Place “Where are you Mr. Doe?” “ Patient states that he is in
Chamberlain hospital”
8. Time “What time is it?” “Patient states that it is 11:00am”
9. Situation- “Can you tell me the reason that you’re here?” “Patients states he/she is
here for a wellness exam ordered by his/her doctor”
Section 3 (Vital Signs) (Will not be included on Return Demo but good to practice)
Can state “Vitals were taken earlier and are within normal limits”
10. “Temperature is 98.6”
11. “Pulse is 66 regular 2+ force”
12. “Respiration is 16”
13. “Oxygen saturation at room air is 99%”
14. “BP is 110/70”
Section 4 (Skin and Nails) “I will now move onto the skin and nails”
15. Inspect Skin
a. Color, Lesions, Wounds, Incisions
16. Inspect Nails
a. Color, Shape/Countour
b. Assess capillary refil
17. “Skin color is consistent with ethnicity”
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