Head to Toe Assessment Guide

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HEAD TO TOE ASSESSMENTGeneral Appearance [inspection] Gender, race, age Signs of distress (angry, pain, anxiety) Affect and mood Orientation x3? (person, place, time), LOC Speech pattern Body type (obese, frail, muscular) Posture, gait, movements Hygiene and grooming Abdomen [inspect, auscultate, palpate, percuss] Know landmarks for each quad Active bowel sounds (every 5-35 sec.) Soft, non-tender Vascular system [inspect, ausculate, palpate] Inspect for bounding or distended pulse arteries & edema Palpate for pulse, palpate edema Auscultate for abnormals Genitals and rectal area [inspect, palpate] voiding sufficient quantity? foley present? last BM? Musculoskeletal system [inspect, palpate] ROM reflexes Abnormals: Abnormals: hernias distention hypo/hyperactive bowel sounds striae palpable masses pulsing masses absent bowel sounds (2-5 min.) bruit bruising absent/weak, thready

Skin, hair and nails [inspect and palpate] Can by done while assessing other body parts or by itself skin should be intact, dry, smooth color congruent for race? mucous membranes should be moist and pink turgor (elasticity) should be immediate pressure areas? Nails smooth

Abnormals:

diaphoresis petechiae cyanosis edema pallor bruising jaundice erythema excessive pigmentation eczema induration ridged or broken nails

delayed capillary refill (>3sec.) phlebitis

Abnormals:

hemorrhoids Lesions/chancres Rectocele/cystocele

discharge

Head [inspect and palpate] Should be upright and still Abnormals: Symmetrical facial features Eyes sclera white, pupil clear, smooth equal movement, PERRLA, ears symmetrical, no drainage mouth membranes pink and moist, palate intact, no swelling in throat neck soft, no swollen lymph nodes carotid arteries palpable dentition Chest and lungs [inspect, auscultate, palpate] Symmetrical expansion with respiration Lung sounds vesicular, broncho-vesicular,bronchial Heart sounds S1 & S2 (lub dub) PMI point of maximal impulse (apex) cough Ease and depth of respirations Peripheral pulses

Abnormals:

paralysis asymmetrical features lesions/sores in mouth/ears drainage/matting in eye glaucoma cataracts strabismus nystagmus ptosis exophthalmos congunctivitis caries varicosities

kyphosis Scoliosis osteoporosis decreased ROM hyper/hypotonicity

lordosis atrophy

Other:

any tubes present (IV, foley, oxygen, etc)? Dressings? Describe type and any drainage present Incisions? Intact with staples, color of surrounding skin, etc.

CRANIAL NERVE ASSESSMENT I II III IV V VI VII VIII IX X XI XII Identify familiar odors Visual Acuity Pupillary response Follow your finger w/o moving head Assess for sharp, dull sensations on face, have patient hold mouth open Follow your finger w/o moving head Have patient smile, differentiate between sweet and sour Hearing: snap fingers close to ears Balance: feet together, arms at sides with eyes closed for 5 sec. Have patient swallow and say Ahh Elicit gag reflex Have patient shrug shoulders Have patient stick out tongue and move from side to side

Abnormals:

adventitious sounds: crackles (rales) rhonchi wheezes pleural S3 or S4 murmers thrill dysrythmia clubbed fingers