Learning Objectives

Describe the purpose and components of a comprehensive head-to-toe assessment.

• The purpose of a comprehensive head-to-toe assessment is to systematically evaluate the overall health status of a patient by examining all body systems. Components include inspection, palpation, percussion, and auscultation of each body system.

• The purpose of a comprehensive head-to-toe assessment is to diagnose specific diseases only. Components include only laboratory tests and imaging studies.

• The purpose of a comprehensive head-to-toe assessment is to focus solely on the cardiovascular system. Components include only auscultation and blood pressure measurement.

• The purpose of a comprehensive head-to-toe assessment is to assess mental health exclusively. Components include only psychological questionnaires and interviews.

Identify normal and abnormal findings during each phase of the head-to-toe assessment including neurological, respiratory, cardiovascular, gastrointestinal, musculoskeletal, integumentary, and genitourinary systems.

• Normal findings include clear breath sounds, regular heart rate, intact skin, normal muscle strength, and alert neurological status. Abnormal findings may include wheezing, irregular heartbeat, skin lesions, muscle weakness, or altered mental status.

• Normal findings include irregular breath sounds, rapid heart rate, broken skin, severe muscle weakness, and confused neurological status. Abnormal findings may include clear breath sounds, regular heartbeat, intact skin, strong muscles, or alert mental status.

• Normal findings include labored breathing, heart murmurs, bruised skin, and decreased muscle tone. Abnormal findings may include clear breath sounds, regular heart rate, and intact skin.

• Normal findings include persistent cough, irregular pulse, open wounds, and slurred speech. Abnormal findings may include clear breath sounds, regular heart rate, and intact skin.

Demonstrate correct sequencing and technique in a head-to-toe assessment.

• The correct sequencing involves starting from the head and moving down to the toes, using appropriate techniques such as inspection, palpation, percussion, and auscultation for each body system.

• Begin the assessment at the feet and move upwards, using only inspection for all body systems.

• Start with the abdomen, then assess the head, and finish with the extremities, using palpation exclusively.

• Assess the body in any random order, focusing mainly on auscultation and ignoring other techniques.

Document assessment findings accurately and concisely using appropriate nursing terminology and electronic charting formats.

• Assessment findings should be documented using precise nursing terminology and entered into electronic health records in a clear, concise, and accurate manner.

• Assessment findings should be documented using layman's terms and handwritten notes for clarity.

• Assessment findings should be recorded only if they are abnormal, using informal language.

• Assessment findings should be summarized verbally to the next shift without written documentation.

Fill in the blank: One reason for comprehensive assessment is to ________ baseline data.

• establish

• ignore

• delete

• misplace

Fill in the blank: Comprehensive assessment helps detect early signs of ________.

• deterioration

• improvement

• celebration

• innovation

Fill in the blank: Comprehensive assessment builds a safe ________ relationship.

• nurse-patient

• teacher-student

• doctor-family

• manager-employee

Fill in the blank: One of the principles of success is to ________ yourself and explain the procedure.

• introduce

• ignore

• confuse

• hide

Fill in the blank: One of the principles of success is to provide _______ and proper lighting.

• privacy

• noise

• food

• exercise

Fill in the blank: One of the principles of success is to ensure patient's _______ and consent.

• comfort

• height

• age

• weight