Head To Toe Assessment
Vital Signs
Name:
DOB:
Allergies:
Admission Dx:
Past Medical History:
HR:
BP:
O2 Stat:
RR:
Temp:
Pain:
Appearance:
Skin/ Skin Breakdown:
Neurological
Alert:
Oriented:
Head and Neck- Check veins at 45 degree angle
Pupils
Appearance:
PERRLA:
Pupil Size:
Palpate:
Bilateral Checks:
Heart Tones:
Rate:
Rhythm:
Hand strength:
Radial pulses:
Clarity:
Abnormal:
Leg Strength:
Pedal Pulses:
Capillary re ll:
Breath Sounds
Anterior:
Posterior:
Bowel sounds- Inspect all 4 quadrants, auscultation, and palpate.
Appearance:
RLQ:
RUQ:
LUQ:
LLQ:
Soft/ Hard/ Distended:
fl
fi
Homan’s Sign- Dorsi ex both feet, assess for pain in calf. (Potential thrombophlebitis)
Pain: