![]() Inquire if the patient has experienced loss of balance, decreased coordination, previous falls, or difficulty swallowing. Ask if headache, dizziness, weakness, numbness, tingling, or tremors are present. If pain or discomfort is present, perform comprehensive pain assessment using PQRSTU. Evaluate for the presence of pain or other type of discomfort.(Initiate emergency assistance as needed.) Ask, “Do you have any concerns or questions you’d like to talk about before we begin?” Evaluate chief concern using PQRSTU (i.e., ask the patient their reason for seeking/receiving care).Address patient needs before starting assessment (toileting, glasses, hearing aids, etc.).Include general appearance, behavior, mood, mobility (i.e., balance and coordination), communication, overall nutritional status, and overall fluid status. Perform a general survey while completing the head-to-toe assessment.Mental Status: Is the patient responsive and alert?.Circulation: Are there any abnormal findings in the overall color and moisture of the patient’s skin (cyanosis, diaphoresis)?.Breathing: Is the patient breathing normally?.Airway: Is the airway open? Is suctioning needed?.Perform a primary survey to ensure medical stability.Identify the patient using two patient identifiers (e.g., name and date of birth). ![]() ![]() Ensure the patient’s privacy and dignity.Use appropriate listening and questioning skills.Explain the process to the patient and ask if they have any questions.Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.Check the room for transmission-based precautions.Perform hand hygiene before providing care and clean stethoscope.Gather supplies: stethoscope, penlight, watch with second hand, gloves, hand sanitizer, and wound measurement tool.Unanticipated findings should be reported per agency protocol with emergency assistance obtained as indicated. Focused assessments should be performed for abnormal findings and according to specialty unit guidelines. Assessment techniques should be modified according to life span considerations. Students should use a systematic approach and include these components in their assessment and documentation. This checklist is intended as a guide for a routine, general, daily assessment performed by an entry-level nurse during inpatient care. Appendix C – Head-to-Toe Assessment Checklist Head-to-Toe Assessment Checklist
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