Marcella Niehoff School of Nursing Baseline Head-to-Toe Assessment
Assessment
Safety
• Side rails up / bed low position & locked
• General condition of the room
• Infection control - handwashing/sanitize
General Survey
• Vital signs (T, P, RR B/P)
• Pain
• LOC
• Orientation (x4)
• PERRLA
• Grip Strength/symmetry
• ROM (upper and lower extremities)
• Balance/Gait
• Head & facial symmetry/ lesions/ abnormalities
Cardiovascular
• Inspect apical area/ PMI
• Auscultate apical pulse (rate and rhythm)
• Auscultate heart sounds 5 locations (diaphragm only)
• Palpate pulses: radial, pedal, posterior tibial
• Capillary refill
• Extremity color
Respiratory
• Inspect thorax (shape, symmetry, use of accessory
muscles)
• Auscultate breath sounds (6 points anterior/posterior,
3 points laterally x2)
• Oxygen
• Pulse oximetry
Integumentary
• Color
• Texture
• Temperature
• Turgor
• Edema (lower extremities)
• Lesions
• Wounds/dressings
GI / GU
• Inspect abdomen
• Auscultate bowel sounds (x4 quadrants)
• *light palpation rebound tenderness
• Last BM / flatus
• Diet /appetite
• I &O
• IV lines / tubes
• Voiding / Foley
Documentation
1/12/21