Head To Toe Assessment Checklist
Wash Hands
( ) Completed - Standard Precautions
Introduction
( ) Completed - Introduce self & purpose of assessment to relieve anxiety and role function identification.
Vital Signs
Pulse__________ Rate, Strength, Regularity
Temperature________ Oral, Rectal, Tympanic
B / P_________ Respiration_______________
Orientation
( Oriented x 4 )
What year is this ? ________________________
Tell me your name ?_______________________
Tell me where you are ? ____________________
Tell me why you are here?__________________
Pupil Check
( PERRLA ) Pupils, Equal, Round, React to light, Accommodate
Sluggish ( ) No Change ( ) Brisk ( ) Normal ( )
Accommodation Yes ( ) No ( )
Neck Veins
Patient at 45o angle ( )
Neck Veins Flat ( ) Distended ( )
Heart Tones
Apical Pulse with Stethoscope
Rate ?_____________ Rhythm ?___________
Clarity of Sounds ? _________ Abnormal ? ( )
Explain ! ____________________________
Bilateral Checks
( Radial Pulses ) - Rate, Strength, Regularity
Right_____________ Left______________
( Hand Strength ) - 2 fingers only
Right Stronger ( ) Left Stronger ( ) Equal ( )
( Pedal Pulses ) - Top of Foot
Right Foot __________ Left Foot ____________
( Capillary Refill ) -On fingers or toes 3 seconds or less
Right Fingers ( ) sec. Left Fingers ( ) sec.
Right Toes ( ) sec. Left Toes ( ) sec. Delay or abnormal refill return ? Yes ( ) ie., ____
Skin
Skin Turgor - 1 to 3 second return, on Sternum
Return was ( ) sec. Abnormal ( ) sec.
Skin Color - Check on inside of Lip or Conjunctiva
Lip ( ) Conjunctiva ( )
Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )
Skin Temperature - Use back of hand to check
Hot ( ) Warm ( ) Cool ( )Breath Sounds
Assess anterior and posterior and from side to side, also right lobe. Have patient take deep breaths, do not move stethoscope to rapidly to avoid hyperventilating on patients part.
Clear Bilaterally ( ) Left only ( ) Right only ( )
Both poor bilaterally ( ) ie.,_________________
Good air flow ( ) Poor air flow ( )
Bowel Sounds
Assess all 4 quadrants, do not touch stomach before auscultation, as it may disrupt normal sounds. If irregular, 5 minute assessment on each quadrant. Umbilicus is mid point.
( Stomach ) - Check for condition
Soft ( ) Hard ( ) Distended ( ) Other
RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypoactive ( )
Peripheral Edema
Edema is found in dependent areas such as the feet, hands, sacrum. Check with finger by pressing down. Observe for pitting or indentation.
Feet Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Hands Yes ( ) No ( ) Pitting ( ) R ( ) L ( )
Sacrum Yes ( ) No ( ) Pitting ( ) Indent ( )
Assessing For Pain
Where is the pain ?________________________
How long has it lasted ?____________________
Does the pain travel anywhere ?_____________
What makes it feel better ?__________________
What makes pain worse ?___________________
Descrip. of pain ? Sharp ( ) Stabbing ( ) Dull ( )
On a scale of 1 - 10, 10 being the worst _______
Skin Breakdown Check
Check entire body for redness or skin breakdown. Check all prominences.
Normal ( ) Abnormal ( ) Explain condition and area effected_________________________
Homan's Sign
Ask patient to dorsiflex both feet.
Pain in right calf Yes ( ) No ( )
Pain in both calfs Yes ( ) No ( )
Closure
Let the patient know you are finished and when you will be back.
Bedrails up ( )Bed in low position ( )Call light in reach ( )
Source : www.accessce.com