Head to Toe Assessment Guide

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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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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.

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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.

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Specializes in ER (My favorite), NICU, Hospice.

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

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Specializes in ER (My favorite), NICU, Hospice.

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.

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

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Specializes in Medical and general practice now LTC.

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.

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

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

mhull said:

PHYSICAL ASSESSMENT GUIDE

NEUROPSYCHOLOGICAL

MENTAL STATUS:

o Oriented...

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

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

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

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Specializes in cardiac-telemetry, hospice, ICU.

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

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