Head to toe health assesment template

[Yellowknife]

I am a mature nurse taking a course in advanced health assessment. I am desperately seeking a apple or pc baed template for comprehenisve health assessment. I have several assignments that require head to toe assessments. Is there anything out there, or does anyone gave a PDF or some sort of set kuo and ready to go template for Cc, demographics, hx,all systems etc?Please advise

[Silverdragon102, BSN]

Moved to the General Nursing Student forum

[JBudd, MSN]

Complete Physical Examination: Head to Toe Guideline for practicing an organized and systematic approach. It is not a replacement for the final checkoff sheet. Remember to always wash your hands upon entering the room, focus on the patient, and introduce yourself.

Patient _________________________________Age_____ Sex___ Occupation____________________

Examiner_________________________________________________

General Survey of Patient

1. Appears stated age __________________________________________________
   
2. Level of consciousness ______________________________________________
   
3. Skin color _________________________________________________________
   
4. Nutritional status ___________________________________________________
   
5. Position___________________________________________________________
   
6. Obvious physical deformities _________________________________________
   
7. Mobility: gait, use of assistive devices, ROM of joints, no involuntary movement
   
8. Facial Expression ___________________________________________________
   
9. Mood and affect __________________________________________________
   
10. Speech: articulation, pattern, content appropriate, native language
    
11. Hearing ___________________________________________________________
    
12. Personal hygiene __________________________________________________
    

Measurement and Vital Signs

1. Weight____________________________________________________________
   
2. Height____________________________________________________________
   
3. Skinfold thickness, if indicated _______________________________________
   
4. Vision using Snellen eye chart ________________________________
   

Right eye____________ Left eye_______________

Correction? _________________________

Radial pulse, rate, and rhythm ____________________________________________

Respirations, rate, depth _________________________________________________

Blood pressure

Right arm ______________________________(sitting or lying?)

Left arm _______________________________ (sitting or lying?)

Temperature ______________________________________________

Stand in Front of Patient, Patient is Sitting

Skin

^Hands and nails _____________________________________________________

*(For rest of exam, examine skin with corresponding region)

Color and pigmentation ___________________________________________

Temperature ___________________________________________________

Moisture _______________________________________________________

Texture _______________________________________________________

Turgor ________________________________________________________

Any lesions ____________________________________________________

Head and Face

1. ^Scalp, hair, cranium ________________________________________________
   
2. ^Face (cranial nerve VII) ____________________________________________
   
3. ^Temporal artery, temporomandibular joint _____________________________
   
4. ^Maxillary sinuses, frontal sinuses _____________________________________
   

Eyes

1. ^Visual fields (cranial nerve II) _______________________________________
   
2. ^Extraocular muscles, corneal light reflex _______________________________


1. ^Cardinal positions of gaze (cranial nerves III, IV, VI) _________________________________
   

[*]^External structures ________________________________________________

[*]^Conjunctivae _____________________________________________________

1. Sclerae ____________________________________________________
   
2. Corneas _________________________________________________
   
3. Irides ______________________________________________________
   

[*]^Pupils ___________________________________________________________

[*]^Ophthalmoscope, red reflex ________________________________________

1. *Disc ______________________________________________________
   
2. *Vessels ___________________________________________________
   
3. *Retinal background __________________________________________
   

Ears

^External ear _______________________________________________________

Any tenderness ________________________________________________________

^Otoscope, ear canal _________________________________________________

^Tympanic membrane __________________________________________

^Test hearing (cranial nerve VIII), voice test _______________________________

^Weber test ___________________________________________________

^Rinne test ____________________________________________________

Nose

1. ^External nose ____________________________________________________
   
2. ^Patency of nostrils _________________________________________________
   
3. Speculum, nasal mucosa _____________________________________________

   Mouth and Throat

   1. ^Lips and buccal mucosa _____________________________________________

      [*]^Tonsils _________________________________________________________

      [*]^Uvula (cranial nerves IX, X) _______________________________________

      [*]^Tongue (cranial nerve XII) _________________________________________

      Neck

      1. ^Symmetry, lumps, pulsations _________________________________________
         
      2. ^Cervical lymph nodes _______________________________________________
         
      3. ^Carotid pulse (bruits if indicated) _____________________________________
         
      4. ^Trachea _________________________________________________________
         
      5. ^ROM and muscle strength (cranial nerve XI) ____________________________
         

      Move to Back of Patient, Patient Sitting

      1. ^Thyroid gland ____________________________________________________
         

      Chest and Lungs, Posterior and Lateral

      1. ^Thoracic cage configuration _________________________________________

         [*]^Symmetric expansion (Palpation ) ____________________________________

         1. ^Tactile fremitus ___________________________________________
            
         2. Lumps or tenderness __________________________________________
            

         [*]^Palpation of spinous processes ________________________________________

         [*]^Percussion over lung fields __________________________________________

         1. ^Diaphragmatic excursion ______________________________________
            

         [*]^CVA tenderness __________________________________________________

         [*]^Breath sounds ____________________________________________________

         [*]Adventitious sounds _________________________________________________

         Move to Front of Patient

         Chest and Lungs, Anterior

         1. ^Respirations and skin characteristics __________________________________
            
         2. Tactile fremitus, lumps, tenderness ____________________________________
            
         3. Percuss lung fields _________________________________________________
            
         4. ^Breath sounds ____________________________________________________
            

         Breasts

         1. Symmetry, mobility, dimpling _________________________________________
            
         2. Supraclavicular and infraclavicular areas ________________________________
            

         Upper Extremities

         1. ^ROM and muscle strength __________________________________________
            

         ^Epitrochlear nodes ________________________________________________

         Patient Supine, Stand at Patient's Right

         2. Breast palpation ____________________________________________________

         1. Nipple ___________________________________________________________
            
         2. Axillae and regional nodes ___________________________________________
            

         Neck vessels

         1. ^Jugular venous pulse ____________________________________________
            
         2. Jugular venous pressure, if indicated ____________________________________
            

         Heart

         1. Precordium: pulsations and heave _____________________________________
            
         2. Apical impulse ____________________________________________________
            
         3. Precordium, thrills _________________________________________________
            
         4. ^Apical rate and rhythm ______________________________________________
            
         5. *Heart sounds (identify S1-S2) ____________________________________
            

         Abdomen

         1. ^Contour, symmetry _________________________________________________

            [*]^Bowel sounds ___________________________________________________

            [*]^Vascular sounds __________________________________________________

            [*]^Percussion ______________________________________________________

            [*]^Liver span in right MCL ____________________________________________

            [*]^Spleen ___________________________________________________________

            [*]^Light and deep palpation ____________________________________________

            [*]^Palpation of liver, spleen, kidneys, aorta ________________________________

            [*]Abdominal reflexes if indicated _______________________________________

            Inguinal Area

            1. ^Femoral pulse __________________________________________________
               
            2. ^Inguinal nodes _________________________________________________
               

            Lower Extremities

            1. ^Symmetry _____________________________________________________

               [*]^Pulses, popliteal __________________________________________________

               1. ^Posterior tibial ____________________________________________
                  
               2. ^Dorsalis pedis _______________________________________________
                  

               [*]^Temperature, pre-tibial edema ________________________________________

               [*]^Toes and nails _____________________________________________________

               [*]Heel to shin bilaterally (cerebral function test) ___________________________

               Patient Sits Up

               1. ^ROM and muscle strength, hips ______________________________________

                  Neurologic

                  1. ^Sensation,

                     [*]^Position sense ___________________________________________________

                     [*]^Stereognosis ______________________________________________________

                     [*]^Cerebellar function, finger-to-nose ___________________________________

                     [*]^Deep tendon reflexes

                     1. Biceps _______________________
                        
                     2. b. Triceps ______________________________________
                        
                     1. Brachioradialis ________________
                        
                     2. d. Patellar ______________________________________
                        
                     1. Achilles ______________________________________________
                        
                     1. ^Babinski Reflex __________________________________________________
                        

                     Patient Stands Up

                     Musculoskeletal

                     1. Walk across room, assess gait_______

                        [*]Walk on tiptoes, then walk on heels ___________________________________

                        [*]Romberg sign ___________________________________________________

                        [*]Shallow knee bend _________________________________________________

                        [*]Touch toes ______________________________________________________

                        [*]ROM of spine _________________________________________________

                        [*]Scoliosis Check __________________________________________________

                        Help Patient Sit Up, Thank patient for time, Depart from patient

                        Sit Up, Thank patient for time, Depart from patient

                        
                        
                     2. Walk, heel to toe ___________________________________________
                        
                     
                     
                  2. *Face_______________________________________________________
                     
                  3. *Arms and hands ____________________________________________
                     
                  4. *Legs and feet ______________________________________________
                     
                  
                  
               2. ^Knees ____________________________________________________
                  
               3. ^Ankles and feet ____________________________________________________________
                  
               
               
            2. ^Skin characteristics, hair distribution _____________________________
               
            
            
         2. Skin characteristics ___________________________________________
            
         3. Umbilicus and pulsations ______________________________________
            
         
         
      2. Skin characteristics ___________________________________________
         
      3. ^Symmetry _________________________________________________
         
      
      
   2. Teeth and gums ______________________________________________
      
   3. Tongue ___________________________________________________
      
   4. Hard/soft palate ______________________________________________
      
   
   
4. Septum ____________________________________________________
   
5. Turbinates __________________________________________________