Head-to-Toe Assessment
Head-to-Toe Assessment
Wash hands
Provide for privacy and explain procedure
Obtain proper lighting and equipment
Wear gloves if indicated
Health History Questions
Medications
Allergies
Past health
Family history
Lifestyle factors
Safety
Vital Signs
Temp
Pulse
Resps
BP
Saturation
Pain (PQRSTU)
General Survey
Behavior
Appearance
Mobility
Neurological
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Behavior/mood
Affect
Level of Consciousness
o Glasgow coma scale (if appropriate)
Orientation (x 3 spheres)
Strength & Movement x 4 extremities
Sensation x 4 extremities
PERRLA
Gait, posture
Responds Appropriately
Speech Clear
EENT
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Discharge (color, odor, amount)
Mucosa
Symmetry
Tenderness
Sinuses
Lymph nodes
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Peripheral Pulse – quality, rhythm, equality
Apical pulse (full minute)
S1 S2 – extra or abnormal sounds
Jugular venous distension
Carotids
CSM x 4 extremities
Edema
Cap refill
Turgor
IV – solution / rate
Cardiovascular
Head to Toe Assessment NSG 1521 Winter 2021 TD
Comments
Respiratory
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Resp – rate, depth & rhythm, effort
Auscultation of Breath Sounds
(anterior/posterior/lateral), air entry, adventitious
sounds
Cough (sputum production; color)
SaO2/Sp02
Use of oxygen (via ____; ____lpm)
Gastrointestinal
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Swallow
Lips, teeth, tongue, mucosa
Nausea, vomiting?
Appetite, diet?
Inspect: size, shape
Auscultation of bowel sounds x 4 quadrants
Palpate: distension, soft/firm, tenderness
Passing flatus?
Last BM __________(characteristics)
Genitourinary
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Continence / catheter
Adequacy of urine output
Urine appearance
Discharge (color, odor)
Burning, frequency, urgency
Reproductive considerations (LMP)
Musculoskeletal
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Muscle symmetry (atrophy?)
Swelling at joints
ROM
Strength
Circulation / Sensation / Movement x 4 extremities
Skin
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Color (& uniformity)
Temperature
Texture
Rashes, lesions, moles, incisions, ulcers, wounds,
dressings (skin intact?-attention to sacrum, heels,
and other bony prominences)
Hair
Nails (clubbing)
Safety
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Fall risk
Isolation Precautions (if applicable)
Environmental check for hazards and personal
belongings within reach
IV’s – sol’n/rate/site/expiration dates
tubes; drains – assess from start/end to insertion
site
Psychological/Social
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Behavior / interaction
Head to Toe Assessment NSG 1521 Winter 2021 TD
Comments