This article describes the basics of a head-to-
Level of Consciousness and
toe assessment which is a vital aspect of
nursing. It should be done each time you
encounter a patient for the first time each
shift (or visit, for home care, clinic or office
nurses).
This assessment includes assessment of the
physical, emotional and mental aspects of all
body systems as well as the environmental
and social issues affecting the patient. The
nurse needs to observe for all of these
factors and ask questions as needed.
Difficulty: Average
Time Required: Approximately 10-20 minutes
Procedure:
1. Assemble your equipment. Wash your
hands. Greet and identify the patient.
Explain what you are going to do.
Provide for privacy. Begin with the 5
Vital Signs: Temperature, Pulse, Blood
Pressure, Respiration and Pain. Ask
the patient how he/she feels and
observe the environment. As you
assess the body by systems, observe
for such tings as non-verbal cues,
mobility and ROM.
2. HEENT/Neuro:
o Head: shape and symmetry;
condition of hair and scalp
o Eyes: conjunctiva and sclera,
pupils; reactivity to light and
ability to follow your finger or a
light
o Ears: hearing aids, pain? Speak
in a whisper: can he hear you
and comprehend? Turn away to
make sure he isn't reading your
lips.
o Nose: drainage, congestion,
difficulty breathing, sense of
smell
o Throat and Mouth: mucous
membranes, any lesions, teeth
or dentures, odor, swallowing,
trachea, lymph nodes, tongue
3.
Orientation: Is he awake and alert? Is
he oriented to Person (knows his
name), Place (he can tell you where he
is) and Time (knows the day and
date). A fourth level of orientation is
Purpose (he knows why you are
examining him; or knows the function
of something such as your penlight or
stethoscope).
4. Skin: As you examine all body systems
you need to make note of the status of
the Integumentary System for any
breaks in the skin, scars, lesions,
wounds, redness, or irritation. Assess
the turgor, color, temperature and
moisture of the skin.
5. Thoracic region: Assess lung and
cardiac sounds from the front and
back. Assess them for character and
quality as well as for the presence or
absence of appropriate sounds.
Palpate the chest wall and breasts for
any tenderness or lumps.
6. Abdomen: Listen to bowel sounds
throughout the 4 quadrants. Palpate
for tenderness or lumps. Palpate the
bladder. Ask about intake and output
of bowels and bladder. Ask about
appetite. Asses genitalia for
tenderness, lumps or lesions.
7. Extremities: Assess for temperature,
capillary fill and ROM. Palpate for
pulses. Note any edema, lesions,
lumps or pain.
8. General Questions: Ask the patient
how he feels. Has anything changed
recently? Any pain, burning, SOB,
chest pains, change in bowel or
bladder habits/function, change in
sleep habits, cough, discharge from
any orifice, depression, sadness, or
change in appetite?
9. Wash your hands.
Document your findings.
Report any significant changes or
findings to the PCP (primary care
practitioner).