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Head to Toe Physical Assessment
POLST/Code Status
VS
7:30
Temperature
Pulse
Respirations
BP
/
Pain
/10
VS
11:30 Temperature
Pulse
Respirations
BP
/
Pain
/10
GENERAL SURVEY
Age___________
How does the client look?
Male/Female
Body Build: Thin
Height___________ Weight____________
Facial Expression:
Anxious
Happy
Cachectic
Obese
Well groomed
Sad
WNL
Poorly Groomed
Angry
NEUROLOGICAL
Alert
Awake
(LOC) Level of
Consciousness
Oriented x 4:
Eyes
Unaided sight
Pupils
Equal
Lethargic
Glasses
Round
Confused
Decerebrate
Decorticate
Response to touch/voice
Contact lens
Reactive to light
Comatose
Implants
Prosthesis
Accommodates
Snellen 20/
Sluggish
Brisk
Blind
Nonreactive to light
Consensual
Pupil size before light ______mm Pupil size after light ______mm
Unaided hearing
Extremities
Hand grips
Pain
Stuper
Person Place Time Event
Ears
Cranial Nerves - intact
Obtunded
Hard of hearing
+1 +2 +3 +4 +5
I(smell)
II(vision)
VIII (hear/balance)
Character
Deaf
Hearing aid
equal unequal
III+IV+VI(eye movement)
IX (taste/swallow)
Onset
Location
Implant
Foot pushes
V(sensation of face/oral)
X (chew/gag/speech)
Duration
Cerumen
+1 +2 +3 +4 +5
Severity
Drainage
equal unequal
VII (facial movement/taste)
XI (shrug/turn head)
Pattern
XII(tongue movement)
Associated Factors
COLDSPA
CARDIOVASCULAR
Skin / Mucous Membranes
Pink
Pale
Cyanotic
Radial and Pedal Pulses
Radial: Palpable (L/R)
Apical Radial Pulses
(2 people simultaneously)
Apical and Radial
Carotid Pulses
(DO NOT TAKE AT SAME TIME)
Right
Capillary Refill
Normal (<3 Sec)
Jugular Neck Veins
Not visible
Edema
Absent
Present: location
Calf Tenderness
Denies
Positive Homan’s sign
Heart Rhythm/
Regular
Sounds – S1S2
Telemetry:
Absent (L/R)
Ruddy
Pedal: (DP PT)
Flushed
Palpable (L/R)
Diaphoretic
Absent (L/R)
Pulse Deficit
Left
Thrill
Bruit
______sec
Visible
Irregular
+1 +2 +3 +4 Anasarca
Pitting
R L calf size R____ L_____
Murmur
Extra sounds
rhythm ___________________
Solution_______________
IV
Jaundiced
Rate
(team leader or charge nurse notified)
Strong
Faint
Pacemaker
____ml/hr
Muffled
Defibrillator
location
Pump
Site location (be specific) ______________________________________
Site appearance: Clear
Erythema
Edema
Dialysis access: type __________
Thrill
Tender
Bruit
Non Pitting
Pallor
Location:___________ Appearance:____________
RESPIRATORY
Respirations
Regular Irregular
Clear
Lung Sounds
LUL
Even
RUL
Uneven
LLL
Unlabored
RLL
RML
Labored
Anterior
Symmetrical
Wheezes location__________
Rales/crackles location__________
Nasal flaring
Intercostal retraction
Sternal retraction
Asymmetrical
Posterior
Rhonchi
location ________
Do lung sounds improve with cough and deep breath? If no, report to team leader
Cough
Oxygen
Respiratory Treatments
ALLERGIES
None
Nonproductive
Room air
Tent
Dry
Moist
Pulse ox ______
CPAP
Productive
Sputum:amount
O2 at_____L/min
Nasal Cannula
medication
frequency
Mask
BIPAP
Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds
HHN
color
Bipap
Ventilator? TV
rate
# of times______
02%
Blood Glucose
other
Gastrointestinal
Oral
Abdomen:
Teeth
Inspect
Soft
Dentures
Round
Caries
Flat
Dysphagia
Scaphoid
Mucous Membranes:
Obese
Firm
Hard
intact
moist
Nondistended
dry
Distended
pale
leukoplakia
Tender
Non Tender
Auscultate Percuss Palpate Location:
Bowel Sounds
RLQ
RUQ
None
NG/ GT/ JT
LUQ
high
Continent
patent
Hypoactive
Hyperactive
Absent
nonpatent
Color of drainage
Incontinent
Diet___________
Nutrition
Normoactive
Type of tube _____
Suction: low
Bowel Movement
LLQ
last BM
amount
Color
Size
Consistency
Ostomy
Stool
% eaten Breakfast____ Lunch_____ NPO? Why___________
Self feed
Needs assistance
Continent
Incontinent
Thickened liquids: honey nectar
pudding
Tube Feed_________________
GENITOURINARY
Urine
Catheter type _______________
Color_________________ Clear
Cloudy
PO/Oral/Tube Feed intake____________
Intake and Output
Fluid restriction
Genitalia
Male
Sediment
Patent
Burning
IV intake____________
Nonpatent________________
Frequency
Urine output_________
Other output
Total I&O + /- ________________
Female
vaginal discharge
LMP
post partum
MUSCULOSKELETAL
Mobility
ADLs independent or assisted with _________________________________________________
Muscle treatment
None
Cast
Brace
Splint
Location
Circulation: color, pulses, cap refill
CMST
RA
LA
RL
Contractures
Not present
Amputation
No
Yes
ROM
AROM
AAROM
Turns self
Mobility
Traction - type
Sensation
LL
traction wt:
Temperature
Antiembolitic Hose:knee/thigh
Present – which extremity?
What % decreased?
Location _______________________________
PROM
CPM
Sits independently
Walks: distance
Limited location___________________
Dangles
Ambulatory assistance: Gait belt
Risk for Falls
Elevate
Motion
Cane
Stands independently
Walker
frequency
Crutches
Walks independently
Braces
tolerance
Wheelchair
Gerichair
PT OT RNA
Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad
Side Rails
Mechanical Lift
Slide Board
integumentary
Intact
Appearance
Color___________
Turgor_____seconds
Skin
Warm
Wound Dressing
None
Pallor
Bruise
Lesions
Scar Location _________________________
Site___________
Hot
Cool
Cold
Dry
Surgical site – Location
Drainage: Color
Moist
Well approximated
Dressing: Dry/intact Non-intact
Pressure Ulcers
Rash
Staples Steristrips
Change: yes no
Amount___________
Wound appearance
Sutures
Odor_________
Drain type _________ Amount______
Stage
Location
Size
Tunneling
Eschar
Slough
Stage
Location
Size
Tunneling
Eschar
Slough
Stage
Location
Size
Tunneling
Eschar
Slough
ISOLATION
Type
Culture
Site
Type
Culture
Site
PSYCHOSOCIAL
Behavior
Restraints
Language spoken
Cooperative
None
Uncooperative
Chemical
Pleasant
Physical: type
CMST of extremity RA
LA
RL
English = speaks and understands
LL
Withdrawn
Combative
Other_______________
location
Frequency Checked________________
See Restraint Form
other_________________ Interpreter
STUDENT(printed)__________________________________________________Date_________Client initials ________Room Number_______
NANDA DX ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Medical DX_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
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