Basic Head-to-Toe Assessment
History of present illness – Brief synopsis of illness from admission to day of care; include treatment and
patients responses.
Name: ______________________________________________________ Date: _____________
Instructor Signature: __________________________________________ Date: _____________
System
Vital signs
Neurological
Cardiovascular
Respiratory
Assessment
Temp, pulse, RR, BP, O2 sat,
Ht/Wt
LOC (Name, Location, Date)
Appropriateness of response,
speech, affect
Pupils (PERRLA)
Gait, handgrips, moves all
extremities equally
Neuro deficits (facial drooping)
Pain: location, rating (0-10),
FACES pain rating scale
Apical pulse
Auscultate landmarks: aortic,
pulmonic, tricuspid, and mitral
valves
Peripheral pulses bilaterally :
brachial, radial, dorsalis pedis
and post tibial (strength and
equality)
Telemetry
Edema (location/pitting or
non-pitting)
Capillary refill/ cyanosis upper
and lower extremities
IV site, fluid (type, rate),
condition
Observe respiratory
rate/rhythm/depth
Auscultate anterior and
posterior lung sounds
Cough: productive/nonproductive
Supplemental oxygen, O2
saturation
Documentation/Comments
System
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Psychosocial
Equipment
Assessment
Mouth: condition of teeth,
moisture and color of mucous
membranes, dentures,
swallowing
Assess in correct order:
Inspection, Auscultation,
Palpation
Abdomen: inspect shape,
auscultate bowel sounds,
palpate and assess for
distention, tenderness, masses
Last BM: (date, color,
consistency, odor, amount
Diet/NPO
NG tube/feeding tube
Assess urine: color, clarity,
odor, amount, burning
Voids, Foley, incontinent,
dialysis
Observe and palpate for
distended bladder
Ask about penile or vaginal
drainage, sexual concerns
LMP (women of childbearing
age)
Range of motion, muscle
strength
Skin color, temp, moisture,
lesions, wounds, open areas
Skin turgor
Cultural, social, spiritual
supports and concerns
Special equipment used for
care (traction, SCD, TED, IS,
etc)
Documentation/Comments