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Appendix C: Adult Health I Head-to-toe Assessment Grading Criteria
(QSEN: PCC, IN, QI, TC, SCY) (CLO: 1, 3, 4, 7, 10, 12, 13)
NAME:
General- 3 points
Correctly Assessed
Wash hands, introduce yourself, Identify your client X2, check for allergies, explain procedure, note VS
Neuro/Head- 4 points
Orientation x4 (place, month, self, situation)
PERRL- if follows commands accommodation and tracking
Inspect scalp, face (mucous membranes), neck (midline, JVD), smile symmetry, tongue movement
Integumentary- 4 points
Color, temp, intactness
Intactness
Lumps, bumps, contusions
Cap refill, skin turgor
Chest- 4 points
Inspect
Auscultate 4 cardiac areas (found by palpation), apical pulse (full minute)
Respiratory Status (field of respirations 4 levels on front, 5 levels on back, 2 levels each side)
Note abnormals (heart sounds, adventitious breath sounds, accessory muscles, rate, rhythm, etc)
GI- 4 points
Inspect
Auscultate x 4 quads (in correct order)
Palpate
BM (last time, color, consistency, amount)
GU- 2 points
Note mode of urination (up with assist, foley, incontinent, etc)
Describe urination (color, amount, appearance, odor, etc)
Musculoskeletal/Extremities- 4 points
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MAE Purposely x 4 (if follows commands)
pulses x 4
Edema (pitting, non-pitting, bilateral, anasarca, etc.)
Hand grip, pushes and pulls present x 4 (if follows commands)
Extra Equipment or Tubing- 2 points
NG (nare’, suction setting, characteristics of secretions)
IV sites, PICC lines, Central lines, etc.(size, type, location, placement date, patency, etc )
Oxygen (type, # of liters)
SCD’s
Feeding Tubes
Medication infusing (gtt rates, compatibility, etc)
Other
Ask Pertinent Questions (if verbal) and Collect Subjective Data- 2 points
Pain
Nausea/vomiting
Psychosocial (anxiety, nervousness, depression, family involvement)
Total Points
/29
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