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Head-to-toe assessment cheat sheet

A head-to-toe assessment follows the same order on every patient: a general survey, level of consciousness, then inspect, palpate, percuss and auscultate system by system.

The one exception is the abdomen, where you listen before you touch.

Built from NurseLingo's RN-written study decks· Updated Oct 2026· Sources

Step	Where/How	Normal Finding
1. General Survey	Overall first impression	Appearance, hygiene, mood Do before touching client
2. LOC	Alertness & orientation baseline	Assess first, every time Change = often earliest neuro sign
3. Order: I-P-P-A	Inspect→Palpate→Percuss→Auscultate	Standard for most systems Light palpation before deep
4. Heart Sounds	APETM landmarks, PMI at apex	PMI: 5th ICS midclavicular Erb's point: S1 = S2 (3rd ICS, LSB)
5. Lung Sounds	Vesicular = normal periphery	Soft, low-pitched Inspiration longer than expiration
6. Abdomen Exception	Auscultate BEFORE palpate	Order: I-A-P-P Protects true bowel sounds
7. Bowel Sounds	Active in all 4 quadrants	Listen 5 full min per quadrant Before calling them absent
8. Skin Turgor	Elastic snap-back = hydrated	Test sternum or forearm Tenting = dehydration
9. Cap Refill	Normal is under 3 seconds	Blanch nail bed, release Slow = poor perfusion
10. Pulses/Edema	2+ pulse, no edema = normal	Grade pulses 0 to 4+ Compare bilaterally
11. DTRs	2+ is a normal reflex	Scale runs 0 to 4+ 3-4+ may mean UMN issue
12. Romberg	No sway = negative (normal)	Feet together, eyes closed Positive = proprioception loss

RN pearl: Everywhere else: look, then touch. Abdomen: listen first; palpation can alter bowel sounds.

Watch: Head-to-toe assessment explained

▶ Head to Toe Assessment Nursing · 10:51 · free on the Nurse Lingo YouTube channel

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Frequently asked questions

What is the order for an abdominal assessment?

Inspect, auscultate, percuss, then palpate. Listening before touching keeps palpation from changing the bowel sounds.

What is a normal capillary refill time?

Under 3 seconds.

Why is level of consciousness assessed first?

A change in level of consciousness is often the earliest sign of neurological decline, such as rising intracranial pressure, so you need a baseline before anything else.

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Sources

Clinical Nursing Skills, 24.3 Nursing Assessment, OpenStax
Clinical Nursing Skills, 27.2 Physical Assessment, OpenStax
Nutrition for Nurses, 4.2 Physical Assessment of Digestive Organs, OpenStax
Medical-Surgical Nursing, 35.4 Neurological Concerns, OpenStax

For study only, not medical advice. Ranges and protocols vary by facility; follow your program and facility policies.