Head-to-Toe Assessment

Assessment conducted by

Date:
Time:

LOC
Alert Drowsy Lethargic
StuporousComa
Orientation
Person
Place
Time
Situation
Vitals
Temp
R
BP
Pulse Ox
Head
Hair
PERLA
Nose
Ears
Mouth
o Midline tongue

o Other:

mm

o Moist
o Lesions
o Dentition
Neck
Carotid pulse
JVD + Trachea midline
Chest
Apical Pulse
Muffled Arrhythmia
Breath Sounds - Anterior
Posterior
Lateral
Chest Symmetry
Skin Turgor (clavicle)
Abdomen
Inspection
Ausculation
o LUQ (active / hyper
o RUQ (active / hyper
o LLQ (active / hyper
o RLQ (active / hyper
Palpation

/ absent)
/ absent)
/ absent)
/ absent)

Temp vs. trunk (warm / cool)

Grip equal and strong
Capillary refill <3 sec
Vein filling rapid

Lower Extremities
Hair present
Edema
Foot strength
Homain's (+ / -) Claudication (+ / -)
Temp vs. Trunk (warm / cool)
Nails Yellowed Thickened Ingrown
Pedal pulse R(palp / doppler) L(palp / doppler)
ROM
/
Strength
Upper R
Upper R
Upper L
Upper L
Lower R
Lower R
Lower L
Lower L
Sensation
General Assessment
Weight/Height
BM
Pain Assessment
Acute/Chronic Intensity (0-10)
Location
Duration
Characteristics
Precipitation
Frequency
Non-verbals
Relief factors
Sleep
Skin Assessment
Description:

Upper Extremities
Radial pulses equal, +2
Courtesy of http://nursing.arizela.com

Courtesy of http://nursing.arizela.com