Head-to-toe assessment and vital signs

How to do a head-to-toe assessment

Other platforms explain it with text and video. In VMS you practice it on the patient.

Nursing (NCLEX)PAMD / DO
Practice it in VR with Blocky

A head-to-toe assessment is the systematic check nurses do at the start of every shift. The order matters less than doing it the same way every time and comparing with the last check.

Step by step

  1. Prepare

    Clean your hands, introduce yourself, confirm the patient with two identifiers, explain and get consent. Close the curtain. [1]

  2. General survey and vital signs

    Look at distress, color, posture and hygiene. Take temperature, pulse, breathing rate, blood pressure, oxygen saturation and pain score. [1]

  3. Neuro

    Level of consciousness, orientation to person, place and time, speech, pupils and movement of all four limbs. [1]

  4. Head and neck

    Eyes, ears, nose and mouth: moisture, lesions and dentures. Neck veins and swallowing. [1]

  5. Heart and lungs

    Listen to heart sounds at the four areas and to the lungs front and back. Note effort and cough. [1]

  6. Abdomen

    Look, listen before you touch, then palpate gently. Ask about last bowel movement, appetite and nausea. [1]

  7. Urine and genitals

    Voiding, color and amount of urine, catheter care. [1]

  8. Extremities and skin

    Pulses, capillary refill, swelling, strength. Skin color, temperature, turgor and pressure points (sacrum, heels). [1]

  9. Lines, drains and safety

    IV site, tubes, dressings and devices. Bed low, call light in reach, fall risk. [2]

  10. Document and report

    Write the findings, compare with the last check and report any change. [1]

Common errors

Practice it in VMS

In VMS you do this on the patient, not on paper: every step goes on the checklist with a score, and in Teach mode Blocky tells you what comes next.

Sources

  1. Open RN, Nursing Skills 2e (Chippewa Valley Technical College) (CC BY 4.0)
  2. NCSBN 2026 NCLEX-RN Test Plan
  3. OpenStax, Clinical Nursing Skills (CC BY 4.0)

Steps adapted from Open RN, Nursing Skills 2e (Chippewa Valley Technical College) and OpenStax, Clinical Nursing Skills, licensed under CC BY 4.0. Facts and steps also follow NCSBN 2026 NCLEX-RN Test Plan. VMS is not affiliated with these organizations. Updated: 2026-10-11.