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What to expect your first year  ›  Assessment checklist

Head-to-toe assessment, step by step

The assessment is the foundation of everything a nurse does — and first year is when the head-to-toe becomes second nature. Walk the order below, check off each step, and use the "normal findings" hints to learn what healthy looks like. Your progress is saved on your device automatically.

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Normal findings

  • Appearance: clean, well-groomed, age-appropriate; no acute distress
  • Posture and gait: upright, moves without assistance or as expected
  • Behavior: alert, cooperative, speech clear and unhurried
  • Note anything that looks like distress first — pain, shortness of breath, confusion — before the routine checks.

Normal findings

  • Temperature: about 97–99.5°F oral in a resting adult
  • Pulse: 60–100 beats/min, regular rhythm
  • Respirations: 12–20 breaths/min, unlabored
  • Blood pressure: commonly near 120/80; trends matter more than one reading
  • Oxygen saturation: 95–100% on room air for most adults
  • Pain: 0 on a 0–10 scale — pain is assessed every time vitals are taken
  • Count respirations for a full minute after taking the pulse — people breathe differently when they know you're watching.

Normal findings

  • Alert and oriented ×4: knows person, place, time, and situation
  • Speech: clear, fluent, appropriate word choice
  • Pupils: equal, round, reactive to light — "PERRLA" is the shorthand you'll see everywhere
  • You start this assessment the moment you say hello — orientation questions confirm it.

Normal findings

  • Head: symmetric, no tenderness; facial movements equal on both sides
  • Eyes: clear conjunctiva, sclera white, vision as usual for the patient
  • Ears: no drainage or pain; hearing intact
  • Nose: midline septum, mucosa pink and moist, no drainage
  • Throat/mouth: mucosa pink and moist, tonsils not enlarged, swallows without difficulty
  • Always work top to bottom and compare left to right — symmetry is your baseline.

Normal findings

  • Heart sounds: regular S1 and S2, no murmurs or extra sounds
  • Pulses: present and equal in all extremities, 2+ strength
  • Capillary refill: under 3 seconds
  • No edema, no complaints of chest pain or palpitations
  • Warm the stethoscope and let the patient breathe normally — rushing the cardiac check is the classic beginner mistake.

Normal findings

  • Pattern: regular, even, unlabored; no use of accessory muscles
  • Lung sounds: clear in all fields, front and back; no wheezing, crackles, or diminished areas
  • Symmetry: chest rises equally on both sides
  • Listen front and back, comparing side to side — have the patient breathe slowly through the mouth.

Normal findings

  • Inspection: flat or rounded contour, no distention or visible masses
  • Auscultation: bowel sounds present in all four quadrants
  • Palpation: soft, non-tender, no guarding
  • Order matters: auscultate before palpating — pressing on the abdomen changes bowel sounds.

Normal findings

  • Range of motion: full and pain-free in major joints
  • Strength: 5/5 (full strength against resistance) in all extremities
  • Gait: steady, no assistance needed, no limping
  • No deformity, swelling, or joint tenderness
  • Strength grades run 0–5; 5/5 is normal and is the shorthand you'll use on every note.

Normal findings

  • Color: even, consistent with patient's baseline; no pallor, jaundice, or cyanosis
  • Temperature and moisture: warm and dry
  • Turgor: skin returns quickly when pinched
  • Integrity: intact everywhere — check pressure points and IV sites especially
  • Skin tells on hydration, circulation, and nutrition all at once — glance at it during every other step too.

Normal findings

  • LOC unchanged from the first pass — still alert, oriented, speech clear
  • Pain re-checked — the number should match or improve, never be ignored
  • Finish with safety: bed low, call bell within reach, belongings accessible. Then document — if it isn't documented, it wasn't done.

The guardrail

This is a study preview so the order feels familiar on day one. Real patient assessments are taught and supervised by your program's faculty and clinical instructors — this page is for learning, not clinical guidance.

Nick is independent and unofficial — unaffiliated with the NCSBN, AACN, CCNE, or any nursing program.