Head to Toe Assessment Age: Height: Mouth Does patient wear dentures? Yes No If yes, full/partial and top/bottom If yes, any problems? ____________________________ Lesions, redness, sores? Yes No If yes, describe _________________________________ Mouth pink and moist? Yes No Sex: Weight: How is patient’s mood and affect? ___________ Neurological Patient alert/lethargic/non-responsive (Circle)? State name & DOB? Correct Incorrect Where are you right now? Correct Incorrect What’s today’s date? Correct Incorrect Can you stick out your tongue? Yes No Review of Systems Are you having any pain right now? Yes No If yes: 1 2 3 4 5 6 7 8 9 10 If yes: where/type of pain_______________________ How is your appetite? Good Fair Poor Any trouble going to the bathroom Yes No If yes, do you need assistance: Yes No Are you having any shortness of breath? Yes No If yes, on exertion/on relaxation? _________________ Is patient on Oxygen? Yes No If yes, type of device/how many L_________________ Have I had to repeat myself, pt. able to hear me? ____ Does pt. have any hearing devices? _______________ Does pt. wear glasses/contacts? __________________ Vitals Blood Pressure _______________________________ (Sitting/Lying/Standing Right/Left Arm/Leg) Pulse Rate: _____________________ (Radial/Apical) Pulse Strength: +4-bounding, +3-full, +2-normal, +1-weak, 0-absent Pulse Ox: _____________________________________ Respirations: __________________________________ Temperature______________________(Oral/Axillary) Hair/Scalp Hair distribution even? Yes No Scalp Lesions? Yes No Color/Consistency of Hair? _______________________ Eyes (Pupils) Equal? Round? Reactive to Light? Accommodation? Size (in mm) _________ Yes Yes Yes Yes No No No No Lungs Breath sounds: (Clear, Crackles, Rhonchi, Wheezes) RUL_________________________ RML ____________________RLL________________ LUL________________ LLL_____________________ Cough? Yes No If yes, productive? Yes No If productive, characteristics of sputum______________ Heart Exam Rate rhythm: Aortic Normal Pulmonic Normal Erb’s Point Normal Tricuspid Normal Mitral Normal Apical pulse (1 min.) ____________ Abdomen- inspect shape/symmetry Is abdomen: Round/Flat/Distended/Non-distended Bowel sounds present in all 4 quadrants? Yes No Hyperactive/Hypoactive/Normal If no, which quadrant is absent: 1 2 3 4 Palpate (light and deep) Abdomen soft, firm, hard? ____________________ Is this tender or does this hurt anywhere Yes No If yes, where? ______________________________ When was last Bowl Movement? ________________ What was color, consistency, “normal” for you? ____________________________________________ Extremities/Pulses- inspect color, temp, appearance, hair consistency Arms: Radial pulses- left and right equal? Yes No Grasps: Weak/Strong? _________________________ Capillary Refill: _______________________________ Legs: Posterior Tibial- left and right equal Yes No 4-bounding 3-full 2-normal 1-weak 0-absent Dorsal pedis- left and right equal? Yes No 4-bounding 3-full 2-normal 1-weak 0-absent Push down on my hands with feet? Yes No This study source was downloaded by 100000785299085 from CourseHero.com on 06-09-2024 21:43:33 GMT -05:00 https://www.coursehero.com/file/38098240/head-to-toe-assessment-tool-1docx/ Abnormal Abnormal Abnormal Abnormal Abnormal Skin Lesions? Yes No Breakdown or Bruising? Yes No Skin color? Normal Abnormal If abnormal, explain_____________________ Edema? Yes No If yes, indicate 1-mild 2-moderate 3-deep 4-very deep If yes, where? __________________________________ Is the skin warm/cold/hot/cool (circle) Nails? Clubbing No Clubbing Nail Coloring? Cyanotic Pink Foley- Yes No If yes: Color of urine____________________________ Consistency____________________________________ Amount of output_______________________________ IV Site: Location: ____________________________________ IV Gauge: ____________________________________ Type of Dressing ______________________________ Type of Fluids/Rate _____________________________ This study source was downloaded by 100000785299085 from CourseHero.com on 06-09-2024 21:43:33 GMT -05:00 https://www.coursehero.com/file/38098240/head-to-toe-assessment-tool-1docx/ Powered by TCPDF (www.tcpdf.org)
