Head-To-Toe Physical

A head-to-toe assessment establishes the patient’s baseline, identifies threats that require immediate action, and detects change before it becomes obvious deterioration. It is not a recital of body systems. Each observation should answer a clinical question: Is this patient oxygenating, perfusing, thinking, moving, eliminating, and protecting their skin as expected for their condition? Assessment is the collection of comprehensive data pertinent to the patient’s condition and forms the foundation of the nursing process. The data guide nursing diagnoses, interventions, communication, and evaluation of response. For an inpatient admission, complete a comprehensive assessment within 24 hours. A full baseline assessment does not replace focused reassessments after a procedure, medication change, fall, deterioration, or new complaint. The patient with new dyspnea needs respiratory and cardiovascular reassessment now; waiting for the next scheduled head-to-toe assessment is unsafe. Most documentation systems organize the assessment into approximately 10 body systems. The exact categories vary, but the assessment should systematically address neurologic, sensory and head/neck, respiratory, cardiovascular and peripheral vascular, gastrointestinal, genitourinary, musculoskeletal, integumentary, endocrine/metabolic, and hematologic/lymphatic or immune findings. Vital signs, pain, functional ability, psychosocial...