Head-To-Toe

A head-to-toe assessment is a structured physical assessment from the client’s general appearance through the neurological, respiratory, cardiovascular, abdominal, genitourinary, musculoskeletal, and integumentary systems. Its purpose is not to complete a ritual sequence. It establishes a defensible baseline, detects change, and connects findings to the next nursing action. Complete a comprehensive assessment on admission, at the beginning of each shift, and whenever there is a notable change in the client’s health status. A focused assessment may be added whenever a symptom or risk requires closer examination; it does not replace the comprehensive assessment when one is due. An RPN may initiate a routine head-to-toe assessment without a separate medical order when the RPN has the required knowledge, skill, and judgment and is working within CNO scope of practice, the client’s assignment, and employer policy. Recognizing a finding and deciding what to do next are separate responsibilities. If the client’s acuity exceeds the RPN’s competence or the assigned level of care, obtain assistance and involve the RN or most responsible provider according to local policy. A head-to-toe assessment is not the...