An Easy Guide to Head-to-Toe Assessment
Physical assessment is one of the most important skills a new nurse will learn. The ability to distinguish between normal and abnormal assessment findings in an acute or critical situation can be lifesaving! Early identification of clinical changes with rapid intervention to restore balance (homeostasis) may not only save a patient’s life, but also her/ his quality of life.
High level assessment skills in chronic disease allows the nurse to determine the individual’s baseline “normal” and using the appropriate language and terms in documentation helps other clinicians to know if the patient is stable or deteriorating.
This Easy Guide to Head-to-Toe Assessment form was developed by Dr. Mary C. Vrtis, Ph.D., MSN, RN to help learners develop and refine their assessment skills. The assessment form was designed for a home health setting and requires minimal equipment. The nurse will use four of the five senses (seeing, hearing, smelling, and touching) and need a stethoscope, blood pressure cuff, pulse oximeter, and penlight. If the patient has wearable technology such as a smart watch and/ or a cardiac monitoring device collect that data as well.
Dr. Vrtis has provided this assessment for free to over 10,000 nursing students and nursing instructors.
The form is copyrighted. You may download a full copy for PERSONAL USE ONLY. Instructors, please refer your students to http://www.nurses-hands.org to obtain their own copy.
We provide the assessment form without charge, but a lot of time, energy, and money has been spent to create and update it. In the past, we have found that some enthusiastic learners have posted the document on third party websites. PLEASE, respect our wishes and do not violate the copyright permissions by doing that.
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