Head to Toe Assessment Guide

  1. 0
    Hello, I'm in my junior year of a BSN program and am finally realizing that it would be of great help to have a checklist to take with me to clinical for the head to toe assessment. I'm fine at doing it, but i always seem to leave something out. I was wondering if anyone has anything of the sort and if they could possibly reply to this post and then be able to email me the document. Thanks!
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  4. 14
    Cut and paste to the word processor of your choice, color code it to make it easier to read at 1st glance. I folded mine in half and then I've laminated it and I keep it in my pocket during clinicals to pull out.


    Head-to-Toe Assessment - Initial Survey: Check ABC’s
    LOC (Awake, alert/lethargic/unresponsive)
    Orientation (to person, place and time)
    Neuro check (PERRLA/Glasgow Coma Scale if appropriate)
    Skin color (pale/pink/ruddy/cyanotic/dusky)
    Skin temp (cool/cold/warm/hot)
    Skin texture (dry/diaphoretic)
    Skin lesions/pressure or statis ulcers/ecchymoses: color, drainage, odors, LxWxD in cm
    VS – T (include route), P, R, BP/5th VS = PAIN
    Apical-rate, S1, S2
    Rhythm (regular/irregular/regularly irregular)
    Intensity (loud/distant)
    O2 and Pulse Ox
    Effort (easy/unlabored)
    Depth (deep/shallow/blowing)/Auscultation-ant/lat/post
    * Chest tubes/need for suctioning/advanced skills, i.e. tactile fremitus/diaphragmatic excursion if applicable
    Upper extremities – if IV present note: gauge, solution, rate and infusion pump/controller. Assess IV site for: warmth, redness, edema, drainage or tenderness.
    Abdomen – inspect (round/flat/obese/distended)
    * Any PEG, G-tube, NG-tube, Dobhoff tube?
    Auscultate (BS present x 4 quads? rhythm of BS – normal/hyper/hypoactive and the intensity – high/low-pitched)
    Palpate (soft/firm/hard/tender to light and deep palpation?)
    Abdomen (continued)
    Bowel: Last BM (size/color/consistency/odor)
    Postop flatus?
    Incontinence – urinary or fecal or both?
    GU: Void/ Foley/ Suprapubic/Fr and balloon size, amount, color, presence of mucus/sediment, odor. Note patency and describe urine in dependent drainage bag tubing.
    Ostomy? (note condition of stoma and skin surrounding stoma/contents of ostomy bag-phalange or bag change/client’s adaptation to ostomy)
    Lower extremities –
    Homan’s sign (negative/positive) - with positive being a bad sign possibly indicative of DVT.
    Pedal pulses (Dorsalis Pedis/Posterior tibial, compare bilaterally, Grading (0 - +4)/check for edema) – pitting (+1 - +4)/nonpitting?
    Capillary refill (brisk/sluggish-how long, >3 seconds)
    ROM, Gait
    Dressings, drains or wounds should be assessed and documented in the order they appear in the assessment – i.e. RUE ā RLE. If a circulation check is done, place that information in the order it was assessed.
    Circulation Assessment, include: color/warmth/pulse/ capillary refill/movement and always compare bilaterally.
    Client Education: Include how client learns best, teaching done and client response.
    rocknroll, oklahomagal, mplovex, and 11 others like this.
  5. 1
    I typed out the documentation for a normal head to toe assessment and taped it to the back of my clipboard. As I'm doing my head to toe I have my clipboard right there and look over it before I leave the pt's room and if there's anything I missed, I can just go back and do it.
    IndyElmer likes this.
  6. 4
    PHYSICAL ASSESSMENT GUIDE
    NEUROPSYCHOLOGICAL



    MENTAL STATUS:

    o Oriented

    o Person

    o Place

    o Time

    o Date

    o Alert

    o Dull Affect



    SPEECH

    o Clear

    o Other_______________



    STIMULUS RESPONSE:

    o Verbal

    o Touch

    o Pain



    BEHAVIOR:

    o Cooperative

    o Uncooperative

    o Combative

    o Anxious

    o Depressed

    o Restless

    o Unresponsive

    o Confused (explain)___________

    o Other (explain)______________



    GENERAL:

    o Syncope

    o Dizziness

    o Malaise

    o Seizures

    o Memory loss

    o Insomnia

    o Other______________________

    COMMENTS:



    HEAD/NECK:

    o Symmetrical

    o Range of motion

    o Oral mucosa

    o Pink

    o Other_______________

    o Moist

    o Dry

    o Teeth present condition___

    o Teeth absent____________



    EYES:

    o Drainage

    o Pupils

    o Equal

    o Unequal

    o React to light

    o Accommodate

    o Sclera

    o White

    o Jaundice

    o Other___________________

    o Conjunctiva

    o Pink

    o Pale

    o Other___________________

    EARS:

    o Drainage

    COMMENTS:



    MUSCULOSKELETAL:

    o Symmetrical muscles

    o Full ROM

    o Absence of joint swelling

    o Full muscle strength

    o Steady gait

    o Other______________________

    COMMENTS:



    RESPIRATORY: Rate_______________

    o Effort

    o Norma;

    o Shallow

    o Hyperpnea

    o Wheezing

    o Dyspnea

    o Apneic periods

    o Orthopnea

    o Labored

    o Painful

    o Other______________

    o Rhythm

    o Regular

    o Irregular

    o Sounds

    o Equal

    o Clear

    o Other

    COMMENTS:



    CARDIOVASCULAR:

    o Apical pulse

    o Regular

    o Irregular

    o Rate______________

    o Jugular Neck Distention

    o Pain



    PERIPHERAL VASCULAR:

    o Pulses RT LT

    o Carotid_____________

    o Radial______________

    o Brachial____________

    o Femoral____________

    o Popliteal____________

    o Posterior tibial_______

    o Dorsalis pedis________

    o Rhythm

    o Regular

    o Irregular

    o Homan’s

    o Pain

    o Blood pressure

    o Right arm

    o Left arm

    COMMENTS:



    GASTROINTESTINAL:

    o Abdomen

    o Soft

    o Distended

    o Painful

    o Rigid

    o Other_________________

    o Bowel sounds

    o URQ

    o LLQ

    o LLQ

    o RLQ

    o Intake/Appetite

    o Percentage____________

    o Dysphagia

    o Trouble chewing

    o Nausea

    o Vomiting

    o Weight loss

    o Weight gain

    o Other_________________



    Food Intolerances:



    BOWEL HABITS:

    o Frequency____________________

    o Diarrhea

    o Constipation

    o Date last BM__________________

    o Aids for elimination____________

    o Color

    o Black

    o Bloody

    o Other________________

    COMMENTS:



    RENAL/UROLOGICAL:

    o Urine flow

    o No problems

    o Urgency

    o Incontinent

    o Burning

    o Hesitancy

    o Dysuria

    o Hematuria

    o Frequency

    o Other_________________

    o Appearance/color_______________

    COMMENTS:



    INTEGUMENTARY:

    o Coloring

    o Skin

    o Pink

    o Cyanotic

    o Jaundice

    o Other_________________

    o Texture/Turgor

    o Dry

    o Moist

    o Inelastic

    o Other_________________

    o Nail beds

    o Pink

    o Pale

    o Cyanotic

    o Capillary blanching__sec

    o Edema

    o Absent

    o Pedal

    o Sacral

    COMMENTS:
    LB_RN2B, Curious1alwys, tbirt39, and 1 other like this.
  7. 0
    Well it was suppost to be in 3 line table but it didn't paste that way....I can email it to you if you im me privately with your address.
  8. 0
    hey can you send me this too? it is really thorough and I think it will help me. Thank you so much!
    Last edit by tnbutterfly on Sep 30, '09
  9. 0
    Just to point out this thread is over 4 years old and as per terms of service please do not post email addresses on here (they will be removed) and to be able to send a pm you need 15 or more posts.
  10. 0
    Thank you for this!! It will really help to gather all the information for report to the instructor and for care maps!
  11. 1
    I LOVE THIS ....THANK YOU FOR POSTING!!!

    Quote from mhull
    PHYSICAL ASSESSMENT GUIDE
    NEUROPSYCHOLOGICAL



    MENTAL STATUS:

    o Oriented

    o Person

    o Place

    o Time

    o Date

    o Alert

    o Dull Affect



    SPEECH

    o Clear

    o Other_______________



    STIMULUS RESPONSE:

    o Verbal

    o Touch

    o Pain



    BEHAVIOR:

    o Cooperative

    o Uncooperative

    o Combative

    o Anxious

    o Depressed

    o Restless

    o Unresponsive

    o Confused (explain)___________

    o Other (explain)______________



    GENERAL:

    o Syncope

    o Dizziness

    o Malaise

    o Seizures

    o Memory loss

    o Insomnia

    o Other______________________

    COMMENTS:



    HEAD/NECK:

    o Symmetrical

    o Range of motion

    o Oral mucosa

    o Pink

    o Other_______________

    o Moist

    o Dry

    o Teeth present condition___

    o Teeth absent____________



    EYES:

    o Drainage

    o Pupils

    o Equal

    o Unequal

    o React to light

    o Accommodate

    o Sclera

    o White

    o Jaundice

    o Other___________________

    o Conjunctiva

    o Pink

    o Pale

    o Other___________________

    EARS:

    o Drainage

    COMMENTS:



    MUSCULOSKELETAL:

    o Symmetrical muscles

    o Full ROM

    o Absence of joint swelling

    o Full muscle strength

    o Steady gait

    o Other______________________

    COMMENTS:



    RESPIRATORY: Rate_______________

    o Effort

    o Norma;

    o Shallow

    o Hyperpnea

    o Wheezing

    o Dyspnea

    o Apneic periods

    o Orthopnea

    o Labored

    o Painful

    o Other______________

    o Rhythm

    o Regular

    o Irregular

    o Sounds

    o Equal

    o Clear

    o Other

    COMMENTS:



    CARDIOVASCULAR:

    o Apical pulse

    o Regular

    o Irregular

    o Rate______________

    o Jugular Neck Distention

    o Pain



    PERIPHERAL VASCULAR:

    o Pulses RT LT

    o Carotid_____________

    o Radial______________

    o Brachial____________

    o Femoral____________

    o Popliteal____________

    o Posterior tibial_______

    o Dorsalis pedis________

    o Rhythm

    o Regular

    o Irregular

    o Homan’s

    o Pain

    o Blood pressure

    o Right arm

    o Left arm

    COMMENTS:



    GASTROINTESTINAL:

    o Abdomen

    o Soft

    o Distended

    o Painful

    o Rigid

    o Other_________________

    o Bowel sounds

    o URQ

    o LLQ

    o LLQ

    o RLQ

    o Intake/Appetite

    o Percentage____________

    o Dysphagia

    o Trouble chewing

    o Nausea

    o Vomiting

    o Weight loss

    o Weight gain

    o Other_________________



    Food Intolerances:



    BOWEL HABITS:

    o Frequency____________________

    o Diarrhea

    o Constipation

    o Date last BM__________________

    o Aids for elimination____________

    o Color

    o Black

    o Bloody

    o Other________________

    COMMENTS:



    RENAL/UROLOGICAL:

    o Urine flow

    o No problems

    o Urgency

    o Incontinent

    o Burning

    o Hesitancy

    o Dysuria

    o Hematuria

    o Frequency

    o Other_________________

    o Appearance/color_______________

    COMMENTS:



    INTEGUMENTARY:

    o Coloring

    o Skin

    o Pink

    o Cyanotic

    o Jaundice

    o Other_________________

    o Texture/Turgor

    o Dry

    o Moist

    o Inelastic

    o Other_________________

    o Nail beds

    o Pink

    o Pale

    o Cyanotic

    o Capillary blanching__sec

    o Edema

    o Absent

    o Pedal

    o Sacral

    COMMENTS:
    soulshine101 likes this.
  12. 5
    Although this thread is 8 years old it's amazing how some information remains pertinent.
    loveandnyc, KSRN2b, oklahomagal, and 2 others like this.


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