Head To Toe Assessment

Front 1

Neurological

Back 1

1. Alert, oriented to person, place and time.
2. Follows commands.
3. PERRLA.
4. Equal strength in all four extremities.
5. Verbal/Nonverbal communication appropriate to situation.
6.Swallowing without difficulty.
7. Sensory perception intact without numbness, tingling, or burning.

Front 2

Respiratory

Back 2

1. Breath sounds clear & symmetrical bilaterally; Anterior, lateral and posterior without use of accessory muscles or signs of labored respirations.
2. No use of supplemental oxygen.
3. Coughs absent or effectively clears secretions.
4. Sputum absent or clear.
5. No tubes or drains.

Front 3

Genitourinary

Back 3

1. No indwelling catheter/ostomy in place.
2. Able to empty bladder without difficulty.
3. No incontinence.
4. Urine clear to amber in color.
5. No penile or vaginal discharge

Front 4

Musculoskeletal

Back 4

1. No joint swelling or tenderness.
2. No range of motion limitation in all four extremities.
3. No muscle weakness.
4. If admitted with assistive device(s) utilizes appropriately to ambulate/transfer independently (includes prosthesis, cane,walker, etc.).

Front 5

Cardiovascular

Back 5

1. Heart sounds: regular pulse. S1/S2 audible.
2. No peripheral edema; upper or lower extremities, sacrum.
3. Capillary refill </= 3 seconds.
4. Pulses palpable bilaterally: radial, DP, PT.
5. Absence of neck vein distention at 30-45 degrees elevation of HOB.
6. No tubes or drains.

Front 6

Gastrointestinal

Back 6

1. Abdomen soft, non-tender and non-distended.
2. Bowel sounds present in all 4 quadrants.
3. No nausea or vomiting.
4. Having stools with own normal pattern, color, consistency.
5. No tubes, drains or ostomies.
6. No visible signs of GI bleeding (oral/rectal).

Front 7

Skin/Integumentary

Back 7

1. Skin, warm, dry and intact, without rash or discoloration.
2. Mucous membranes moist.
3. Any dressing, if present, dry and intact.
4. If no dressing, surgical incision is dry and intact with wound edges well approximated; no redness, swelling, odor or drainage at incision site.
5. IV if present without redness, swelling or discoloration.

Front 8

Pain

Back 8

1. Pain equal to or less than 4 and/or at acceptable level for patient.