Head to Toe Assessment Guide
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This is a discussion on Head to Toe Assessment Guide in General Nursing Student, part of Nursing Student ... Hello, I'm in my junior year of a BSN program and am finally realizing that it would be of great...
by kmalensek Mar 15, '05Hello, 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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Mar 16, '05 by mom2michaelCut 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. - Mar 17, '05 by MistyLouI 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.
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Mar 17, '05 by mhullPHYSICAL ASSESSMENT GUIDENEUROPSYCHOLOGICAL
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: - Mar 17, '05 by mhullWell 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.
- Sep 29, '09 by SierraMichellehey 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
- Admin
Sep 30, '09 by Silverdragon102Just 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. - Jun 24, '12 by kellenburgThank you for this!! It will really help to gather all the information for report to the instructor and for care maps!
- Jun 26, '12 by LB_RN2BI LOVE THIS ....THANK YOU FOR POSTING!!!
Quote from mhullPHYSICAL ASSESSMENT GUIDENEUROPSYCHOLOGICAL
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: - Asst. Admin
Jun 26, '12 by Esme12Although this thread is 8 years old it's amazing how some information remains pertinent.
