Head to Toe Assessment Revised
Post on 22-Oct-2014
HEAD- Normocephalic Scalp and hair LOC/Speech: State full name/DOB Where are you now? Why are you here? Current US President? Pain Do you have pain right now? Pupils PERRLA Sclera Palpebral conjunctiva-lining of eyelid Nose- Symmetry Drainage? Easy breathing/closed mouth? Ears Symmetry Drainage? Whisper test Mouth Dentures? Lesions? Tongue, midline and mobile? Pink and moist Neck Tender, swollen nodes? Trachea, midline? JVD Semi-Fowlers Carotid Pulses (separately) UPPER EXTREMITIES -Symmetry Edema? Hand grips/muscle strength/ROM Sensation Cap refill Equal radial pulses? CHEST Turgor top of sternum Heart sounds Aortic 2nd ICS/R SB Pulmonic 2nd ICS/L SB Erbs Point 3rd ICS/L SB Tricuspid 4th ICS/L SB Mitral 5th ICS/ L MCL Apical Pulse 1 full minute
Breath Sounds Anterior Posterior Lateral (3 lobes on right)
ABDOMEN -Order of Assessment Inspection Auscultation Percussion Palpation Bowel Sounds RLQ, RUQ, LUQ, LLQ Last BM? Normal for you? If no BM, flatus? GENITOURINARY- normal genitalia? Catheter?/Tubes? Voiding Pain? Difficulty? Evaluate urine for: Color Clarity Amount LOWER EXTREMITIES Symmetry Edema? Muscle strength/ROM Sensation Cap refill Equal pulses Dorsalis pedis Posterior tibial SKIN Evaluate as you go for Color Pallor? Jaundice? Temperature Warm Moisture - Dry Turgor elasticity Lesions, dressings, wounds Edema Braden Scale No Risk 19-23 At Risk 15-18 Moderate Risk 13-14 High Risk 10-12
Very High Risk 9 or less Warm, dry and intact over bony prominences with a Braden Scale score of 23.