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Head to Toe Assessment Guide

Updated | Posted
by kmalensek kmalensek (New) New

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!

mom2michael, MSN, RN, NP

Specializes in Rural Health.

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.

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.

mhull

Specializes in ER (My favorite), NICU, Hospice. Has 8 years experience.

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

mhull

Specializes in ER (My favorite), NICU, Hospice. Has 8 years experience.

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.

SierraMichelle

Has 4 years experience.

Hey can you send me this too? It is really thorough and I think it will help me. Thank you so much!

Silverdragon102, BSN

Specializes in Medical and general practice now LTC. Has 33 years experience.

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.

Thank you for this!! It will really help to gather all the information for report to the instructor and for care maps!

LB_RN2B

Has 11 years experience.

I LOVE THIS ....THANK YOU FOR POSTING!

mhull said:

PHYSICAL ASSESSMENT GUIDE

NEUROPSYCHOLOGICAL

MENTAL STATUS:

o Oriented...

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Although this thread is 8 years old it's amazing how some information remains pertinent.

LB_RN2B

Has 11 years experience.

Yes !! This will really help me out in my first nursing semester!!

Stcroix, ASN, RN

Specializes in cardiac-telemetry, hospice, ICU. Has 6 years experience.

Here is a short form I use, from school, hope it comes through and it is of use.

Head to Toe 3.16.11.doc

LB_RN2B

Has 11 years experience.

Stcroix said:
Here is a short form I use, from school, hope it comes through and it is of use.

DOWNLOADED AND SAVED!!

I will def be carrying this in my clipboard for clinicals!!! Thank you so much

shay&lynn, ASN, RN

Specializes in Nursing Assistant. Has 4 years experience.

Your schools don't give you an assessment sheet?