HEAD TO TOE ASSESSMENT

Introduce yourself and take vital signs

• BP, pulse rate, RR, O2 sat
• Ask about overnight events, how they slept
• Ask about changes in breathing or any new symptoms
• Ask about current symptoms they have been or are at risk for experiencing
related to their condition (e.g. nausea, dizziness, numbness, palpitations, pain)
Head/Neck
Observe (during vitals or as you are interacting)
• General ability to breath easily, level of alertness, ability to answer questions
and interact appropriately
• Color and condition of their mucosa (mouth and tongue) while they talk or when
you put in the thermometer; condition of teeth and presence of dentures or
bridges
• Head and face for size, shape, symmetry, position, and expression
• Ear canals for drainage, hearing aide
• External nose for edema, discharge
• Eyes for position, alignment of eyes
• Ability to hear
• Movement of mouth and face while interacting
• Skin color and position of trachea
Assess/Examine
• Examine pupils for shape, size, symmetry reaction to light
• Observe skin color and position of trachea
• JVD or other pulsations in neck
Anterior Chest/Abdomen
Observe/Assess
• Respiratory effort, use of accessory muscles
• Observe for rhythm, depth, and symmetry of chest movement
• Observe for cough, note severity and describe output
• Note size, symmetry, contour of abdomen
Auscultate
• Heart sounds
• Anterior breath sounds
○ Apices and bases of upper lobe (total 4 spots, 1 cycle each spot unless
worried or primary diagnosis)
○ RML breath sounds if able
• Bowel sounds x4 quadrants
Palpate
 • Abdomen x4 quadrants
• Chest for AP-lateral diameter
Back
Observe/Assess
• Spinal deformity
• Respiratory effort and equal expansion
• Pressure areas over shoulders/sacrum
Auscultate
• Posterior breath sounds: apices of upper and lower lobes, bases of lower lobes
(total 6-8 spots, 1 cycle each spot unless worried or primary diagnosis)
• RML if not already done
Extremities – Arms
Observe/Assess
• Temperature and moisture (briefly!)
• Nails for color, clubbing
Palpate
• Cap refill
• Radial pulses simultaneously
• Strength – request pt to squeeze fingers simultaneously

Extremities – Legs & Feet

Observe/Assess
• Temperature and moisture (briefly!)
• Nails for color, clubbing
Palpate
• Cap refill
• DP, PT (feel bilateral feet simultaneously)
• Strength – request pt to lift feet up toward head against resistance, push down
(gas pedal) against resistance
• Edema across top of foot, ankles, and up shin (further if needed)
When mobilizing patient
• Assess ROM – active against resistance preferable but perform passive ROM if
pt cannot move
• Assess balance (with eyes closed), posture, body alignment, symmetry, gait
while standing  walking
• Inspect symmetry and shape of muscles and joints