This document provides guidance on performing a head-to-toe health assessment. It recommends beginning with a general survey of the client to observe gait, posture, eye contact and other details. The assessment should then obtain a history, check vital signs and vision, and prepare the client for examination. A focused assessment accommodating the client's needs should examine each body system in an organized, systematic manner. Practicing assessments is emphasized to learn consistency and inclusiveness when examining clients.

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Head-to-Toe Examination and
Documentation
NUR 200
Module C
Health Assessment

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Performing a Health Assessment
• Assessment begins with general survey
when first meeting client
– Observe client enter room, note gait, posture,
and ease of movement
– Shake hands, note eye contact and firmness
of hand grip
– Introduce self—data collection begins by
asking client reason for seeking care

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Performing a Health Assessment
• Assessment should begin with general
survey when first meeting client
– Note language spoken; gross hearing and
speech capability
– Observe for obvious vision difficulties/
blindness; difficulty standing, sitting, or rising

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Performing a Health Assessment
• Assessment should begin with general
survey when first meeting client
– Observe musculoskeletal difficulties
• General affect; interest, and involvement
• Dress and posture
• General mental alertness, orientation, and
integration of thought processes
• Obvious shortness of breath or posture that
facilitates breathing
• Obesity, emaciation, or malnourishment

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Performing a Health Assessment
• After initial observations—obtain history,
assess vital signs/vision, and prep for
exam
• Instruct to empty bladder (collect specimen
if necessary)
• Remove clothing, put on gown, and sit on
exam table
• Conduct a focused assessment that
accommodates client’s needs

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Performing a Health Assessment
• Use following sequence only as guide. It
was developed to demonstrate how one
body system exam is integrated with other
body systems to permit a comprehensive
regional assessment
• Most important:
– Be organized
– Develop a routine (helps with consistency)

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Performing a Health Assessment
• Before beginning assessment, have
clear picture in mind of what you plan
to do and in what order
• Practice, practice, practice—learn to
become systematic and inclusive
• Imagine yourself as client—consider
how you would want nurse to be
prepared for your assessment

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Online Interactive Exercises
• Putting It All Together
http://www.coursewareobjects.com/objects/hao/wils
on3e_v1/ch27/ie/27-001ep.htm
• Equipment Readiness
http://www.coursewareobjects.com/objects/hao/wils
on3e_v1/ch27/ie/27-002ep.htm
• Patient Exam Instructions
http://www.coursewareobjects.com/objects/hao/wils
on3e_v1/ch27/ie/27-003ep.htm