Head-to-Toe Assessment Checklist for Nursing Students

A head-to-toe assessment goes in the same order every time so you never miss a system. Use this checklist in clinicals until it becomes automatic.

The four techniques (IPPA)

Inspect, palpate, percuss, auscultate. Use this order for every system except the abdomen, where you inspect, auscultate, then percuss and palpate. Touching the belly first can change the bowel sounds.

Checklist

1. General survey: how the patient looks, acts, and speaks. Signs of distress, hygiene, and posture.
2. Vital signs and pain: temperature, pulse, respirations, blood pressure, oxygen saturation, and a pain score.
3. Neuro: level of consciousness, orientation, pupils (PERRLA), speech, hand grips, and movement of all four limbs.
4. Head, eyes, ears, nose, and throat: symmetry, drainage, moist mucous membranes, and swallowing.
5. Lungs: breathing rate and effort, chest movement, and lung sounds front and back.
6. Heart: apical pulse, S1 and S2, rhythm, capillary refill, pulses, and edema.
7. Abdomen: shape, bowel sounds in all four quadrants, tenderness, last bowel movement, and diet.
8. Genitourinary: urine output, color, catheter care, and pain with urination.
9. Skin: color, temperature, turgor, wounds, pressure injuries, and IV sites.
10. Musculoskeletal: range of motion, strength, gait, and fall risk.
11. Psychosocial: mood, coping, support system, and safety concerns.
12. Safety check: bed low and locked, call light in reach, alarms on, and lines labeled.

Red flags to report right away

• New confusion or a change in level of consciousness
• Unequal or non-reactive pupils
• New trouble breathing, stridor, or SpO2 dropping
• Chest pain or a new irregular rhythm
• Cold, pale, or pulseless limb
• Rigid, board-like abdomen

Want to learn the sounds? See Lung sounds explained.

Quick answers

For learning only. Lab ranges and policies vary. Always follow your nursing program, a current drug reference, and your facility's policies.