9/7/23, 9:23 PM 2.5 Head-to-Toe Assessment – Clinical Procedures for Safer Patient Care
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CLINICAL PROCEDURES FOR SAFER PATIENT CARE
CONTENTS
Chapter 2. Patient Assessment
2.5 Head-to-Toe Assessment
A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each
shift, and when it is determined to be necessary by the patient’s hemodynamic status and the con‐
text. The head-to-toe assessment includes all the body systems, and the findings will inform the
health care professional on the patient’s overall condition. Any unusual findings should be fol‐
lowed up with a focused assessment specific to the affected body system.
A physical examination involves collecting objective data using the techniques of inspection, pal‐
Previous: 2.4 Health History
pation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 out‐
lines the steps to take. Next: 2.6 Initial and Emergency Assessment
https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/ 1/14
, 9/7/23, 9:23 PM 2.5 Head-to-Toe Assessment – Clinical Procedures for Safer Patient Care
CHECKLIST 17: HEAD-TO-TOE ASSESSMENT
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
Perform hand hygiene.
Check room for contact precautions.
Introduce yourself to patient.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain process to patient.
Be organized and systematic in your assessment.
Use appropriate listening and questioning skills.
Listen and attend to patient cues.
Ensure patient’s privacy and dignity.
Assess ABCCS (airway, breathing, circulation, consciousness,
safety)/suction/oxygen/safety.
Apply principles of asepsis and safety.
Check vital signs.
Complete necessary focused assessments.
STEPS ADDITIONAL INFORMATION
Previous: 2.4 Health History
Next: 2.6 Initial and Emergency Assessment
https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/ 2/14
Home Read Sign in
Search in book …
Want to create or adapt books like this? Learn more about how Pressbooks
supports open publishing practices.
CLINICAL PROCEDURES FOR SAFER PATIENT CARE
CONTENTS
Chapter 2. Patient Assessment
2.5 Head-to-Toe Assessment
A comprehensive head-to-toe assessment is done on patient admission, at the beginning of each
shift, and when it is determined to be necessary by the patient’s hemodynamic status and the con‐
text. The head-to-toe assessment includes all the body systems, and the findings will inform the
health care professional on the patient’s overall condition. Any unusual findings should be fol‐
lowed up with a focused assessment specific to the affected body system.
A physical examination involves collecting objective data using the techniques of inspection, pal‐
Previous: 2.4 Health History
pation, percussion, and auscultation as appropriate (Wilson & Giddens, 2013). Checklist 17 out‐
lines the steps to take. Next: 2.6 Initial and Emergency Assessment
https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/ 1/14
, 9/7/23, 9:23 PM 2.5 Head-to-Toe Assessment – Clinical Procedures for Safer Patient Care
CHECKLIST 17: HEAD-TO-TOE ASSESSMENT
Disclaimer: Always review and follow your hospital policy regarding this specific skill.
Safety considerations:
Perform hand hygiene.
Check room for contact precautions.
Introduce yourself to patient.
Confirm patient ID using two patient identifiers (e.g., name and date of birth).
Explain process to patient.
Be organized and systematic in your assessment.
Use appropriate listening and questioning skills.
Listen and attend to patient cues.
Ensure patient’s privacy and dignity.
Assess ABCCS (airway, breathing, circulation, consciousness,
safety)/suction/oxygen/safety.
Apply principles of asepsis and safety.
Check vital signs.
Complete necessary focused assessments.
STEPS ADDITIONAL INFORMATION
Previous: 2.4 Health History
Next: 2.6 Initial and Emergency Assessment
https://opentextbc.ca/clinicalskills/chapter/2-2-head-to-toe-assessment-checklist/ 2/14
