Nursing Field Notes / Nursing Core · Fundamentals of Nursing

Head-to-Toe Assessment 🚶

The full systematic exam, top to bottom, in order

NG-190 Nursing Core ADHD-friendly visual edition

This is the master reference page for the batch — the sequence that ties everything together. It leans on NG-079 Vital Signs for normal ranges and NG-082 Assessment Locations for exact pulse/auscultation landmarks, so you're not re-learning them here — just placing them in the walk-through.

📄 Simple Nursing original — opens in Drive →

🧾 Consent → privacy → handsAlways before you touch the client.

🚶 Head → neck → chest → abdomen → extremitiesOne direction, never skip around.

🩻 IAPP for the belly onlyInspect → Auscultate → Percuss → Palpate.

📌 Not all programs teach DTR/CN/breastCheck your school manual & state practice act.

🧾

BEFORE YOU BEGIN

STEP 1 · PREP

Six things happen before your hands ever touch the client — every single time.

✅ Pre-assessment checklist

👋 Introduce yourself

🚪 Provide privacy

🧼 Wash hands

📝 Obtain consent

⚠️ Assess for allergies

🧠 Obtain a psychosocial assessment

🧠 "I Prep With A Plan" — Introduce, Privacy, Wash hands, Allergies, Psychosocial, (consent tucked in with intro). Do this before the first vital sign.

🌡️ Normal vitals baseline — quick cross-ref

Vital	Typical adult reference range
BP	<120/<80 mmHg (typical normal; staged hypertension begins ≥130/80)
Pulse	60–100 bpm
RR	12–20 breaths/min
Temp	~98.6°F / 37°C
SpO2	>95%

FULL DETAIL NG-079 Vital Signs — hedged reference ranges, classification tiers, and why "normal" varies by source.

🚶

HEAD TO TOE, IN ORDER

STEP 2 · THE WALK-THROUGH

Same direction every time — head/neck, chest, abdomen, extremities/circulation. Consistency is what lets you spot when something's off.

🧍 The eight-stop sequence

(if in scope) 7 Abdomen (IAPP) 8 Extremities / circulation

🧠 "HEN-CAB-E" — Head, Eyes/ENT, Neck, Chest, Abdomen, Breast, Extremities. Same order, every client, every time — that consistency is what makes a change stand out.

🧑‍⚕️ Head & neck

Hair — clean, well-kept?
Cranial nerves assessed (if in program scope)
Eyes — PERRLA, sclera white, conjunctiva pink/moist, no debris/drainage
Nares — check patency, occlude one nostril at a time
Mouth — oral mucosa pink & moist, no caries/redness/lesions; tongue midline
Jaw/neck — palpate for swollen or painful lymph nodes

🧠 PERRLA = Pupils Equal, Round, Reactive to Light & Accommodation.

🫁 Chest — heart, lungs, breast

Heart: 5-point auscultation (Aortic → Pulmonic → Erb's → Tricuspid → Mitral)
Lungs: RR should be even & unlabored; auscultate anterior + posterior ladder
Breast (if in scope): check for lumps, drainage, nipple size/color changes

FULL DETAIL NG-082 Assessment Locations — the exact 5 heart points and lung auscultation ladder.

🫃 Abdomen

Shape: flat, non-pulsating, even
Bowel sounds: active in all 4 quadrants; if absent, listen 5 min before charting "absent"
Order: Inspect → Auscultate → Percuss → Palpate
Ask about pain on palpation

FULL DETAIL NG-082 Assessment Locations — the four-quadrant map.

🦵 Extremities & circulation

Peripheral pulses: radial, brachial, femoral, popliteal, dorsalis pedis, posterior tibialis (never palpate both carotids at once)
Capillary refill: <3 sec
Skin turgor: returns <3 sec; skin warm, dry, intact
Temperature equal in all extremities
ROM in all joints + DTRs (if in program scope)

FULL DETAIL NG-082 Assessment Locations — every pulse landmark, illustrated.

📌 Program note: not every nursing program teaches DTRs, cranial nerve exams, or breast exams as part of the routine head-to-toe — check your school's skills manual and your state's nurse practice act before performing/omitting them.

🚩

NORMAL vs RED FLAG

STEP 3 · KNOW THE DIFFERENCE

Same eight stops — here's what "normal" looks like next to what should make you stop and reassess.

📋 System-by-system: normal vs red flag

System	Normal finding	Red flag
Eyes	PERRLA, sclera white	Unequal/nonreactive pupils
Neck	No swollen/painful nodes	Tender, enlarged lymph nodes
Lungs	Even, unlabored RR 12–20	Crackles, wheezes, rhonchi, labored breathing
Heart	Regular rate & rhythm at all 5 points	New murmur, irregular rhythm
Abdomen	Flat, non-pulsating, active bowel sounds x4	Rigid/board-like, absent sounds x5min, pulsating mass
Pulses	2+ bilateral, equal	Absent, markedly unequal, thready/weak
Skin	Warm, dry, intact; cap refill & turgor <3s	Cool/clammy, tenting, cap refill >3s, cyanosis

🚨 Priority combo: rigid belly + fever + tachycardia

Board-like abdomen, fever >100.3°F, rebound tenderness, restlessness, tachycardia/tachypnea = suspected peritonitis — report to the HCP as a priority.

⚠️ NCLEX trap: skipping the sequence

Jumping around the body (e.g., checking a pulse, then eyes, then coming back to the chest) increases the chance of missing a finding. Stick to head-to-toe order every time.

🩻 IAPP — the one order that flips for the abdomen

Touching the belly before listening can stir up bowel sounds and give a false reading — so auscultation jumps ahead of percussion and palpation for this one system only.

🗺️ This page in the batch

NG-079 Vital Signs — the normal reference ranges used throughout this exam.

NG-082 Assessment Locations — the exact landmarks for every pulse, heart point, lung stop, and bowel quadrant referenced above.

NG-041 Hypothermia — what happens when the temperature stop on this exam is dangerously abnormal.

⚡

QUICK RECALL

SAY IT OUT LOUD

🧾 6 prep stepsintro, privacy, hands, consent, allergies, psychosocial

🚶 Head → toe, alwaysnever skip around the body

🩻 Abdomen = IAPPauscultate before you touch

🩺 Vitals + Locationsthis page is the index — see NG-079 & NG-082 for detail

🎯 Cover & check — 4 rapid-fire questions

Q1: What six things happen before the nurse touches the client?

Introduce yourself, provide privacy, wash hands, obtain consent, assess for allergies, obtain a psychosocial assessment.

Q2: What is the correct order for abdominal assessment, and why does it differ from other systems?

Inspect, Auscultate, Percuss, Palpate — palpating first can artificially stimulate bowel sounds and give a false reading.

Q3: The client has a rigid, board-like abdomen, a fever, and tachycardia. What's the priority?

Suspect peritonitis — report to the HCP immediately; this is a priority finding.

Q4: Where would you go for the exact landmarks of the pulse points and heart/lung auscultation sites mentioned in this exam?

NG-082 Assessment Locations — this page (NG-190) is the index; NG-082 has the full illustrated detail.