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# Nursing assessment: head-to-toe and focused assessment

- Topic

Nursing assessment is the first stage of the nursing process: gathering data about the patient to plan their care.

Updated 2026-11-01

## Key points

- Types: initial or comprehensive (head-to-toe), problem-focused, emergency (ABC first) and time-lapsed.
- Subjective data (what the patient or family report) and objective data (vital signs, exam, results).
- Primary source: the patient; secondary sources: family, the medical record, other professionals.
- In the abdomen the order changes: inspection, auscultation, percussion and palpation, so bowel sounds are not altered.
- In Colombia nursing assessment is often organised by Marjory Gordon's 11 functional health patterns.
- An abnormal finding or acute change is reported to the team at once, in a structured format such as SBAR.

## What it is

Assessment is the first phase of the nursing process (assessment, diagnosis, planning, implementation and evaluation). It may be initial or comprehensive, head to toe on admission; focused on one problem; emergency, centred on airway, breathing and circulation; or time-lapsed, repeated over time. It combines subjective data, which the patient reports, and objective data, which the nurse measures or observes.

## Key facts

- Focused assessment: directed at the current problem, for example chest pain or the post-operative period.
- Emergency assessment: airway, breathing and circulation first; then a secondary survey.
- Common scales: pain, Glasgow, fall risk and pressure-injury risk.
- Assessment is continuous: it is repeated according to the patient's condition and the care plan.

## Step by step

- Hand hygiene, introduce yourself, verify identity with two identifiers and explain the procedure.
- General impression: level of consciousness, appearance, breathing difficulty, pain.
- Vital signs and pain score: 'From 0 to 10, how much pain do you have now?'
- Head and neck, chest (respiratory and cardiovascular), abdomen, genitourinary and limbs, in head-to-toe order.
- Skin throughout: integrity, pressure areas, wounds, lines and tubes.
- Risks: falls, pressure injuries, nutrition, elimination, sleep and self-care.
- Record the findings and compare them with the previous assessment.
- Report changes: situation, background, assessment and recommendation (SBAR).

## Memory aid

Head to toe and worst to least: first what threatens life, then the full sweep.

## Test yourself

Think of the answer, then tap the question to see it.

## What are the stages of the nursing process?

Assessment, nursing diagnosis, planning, implementation and evaluation.

## In what order is the abdomen examined, and why?

Inspection, auscultation, percussion and palpation: listening before touching avoids changing the bowel sounds.

## How does a comprehensive assessment differ from a focused one?

The comprehensive assessment covers the whole body and sets a baseline on admission; the focused one targets a specific problem, such as pain or a wound.

## What does SBAR stand for when reporting a finding?

Situation, background, assessment and recommendation: a fixed order for reporting to the team without leaving out data.

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## Related

- [Vital signs: what they are and how to record them](https://durgical.com/en/clinical-exam/vital-signs-what-they-are-and-how-to-record-them/)
- [Pain assessment and pain scales](https://durgical.com/en/clinical-exam/pain-assessment-and-pain-scales/)
- [Level of consciousness and the Glasgow Coma Scale](https://durgical.com/en/clinical-exam/level-of-consciousness-and-the-glasgow-coma-scale/)
- [Abdominal auscultation: bowel sounds and bruits](https://durgical.com/en/clinical-exam/abdominal-auscultation-bowel-sounds-and-bruits/)
- [Early warning scores: NEWS2 and qSOFA](https://durgical.com/en/clinical-exam/early-warning-scores-news2-and-qsofa/)
- [Comprehensive geriatric assessment: function, cognition, falls](https://durgical.com/en/clinical-exam/comprehensive-geriatric-assessment-function-cognition-falls/)

## Related conditions

- [Pressure injury (pressure ulcer)](https://durgical.com/en/conditions/pressure-injury/)
- [Falls in older adults](https://durgical.com/en/conditions/falls-in-older-adults/)

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Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.

Sources: [12.2 Types of Assessment - Fundamentals of Nursing | OpenStax](https://openstax.org/books/fundamentals-nursing/pages/12-2-types-of-assessment) (OpenStax, Rice University, 2024); [12.3 Collection of Assessment Data - Fundamentals of Nursing | OpenStax](https://openstax.org/books/fundamentals-nursing/pages/12-3-collection-of-assessment-data) (OpenStax, Rice University, 2024); [2.4 Therapeutic Communication - Fundamentals of Nursing | OpenStax](https://openstax.org/books/fundamentals-nursing/pages/2-4-therapeutic-communication) (OpenStax, Rice University, 2024).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/nursing-assessment-head-to-toe-and-focused-assessment/