Head To Toe Assessment

Front 1

Neurological

Back 1

Check subjective,objective data

I am going to check your pupils by flashing a light into your eyes

Pupils should constrict (Pupils Equal Round and Responsive to light)

Follow Command (can you Follow my pen light)

Alert and Oriented (Person, Place, Time,Situation)

Tell me your full name?

What is today's date?

Why are you here today?

(If patient answers questions correctly, patient is Alert and Oriented ×4) (If patient doesn't answer correctly you would note which one patient is Alert and Oriented too)

Short Term Memory- what did you eat for breakfast?

Long Term Memory- what is your birthday? (short and long term memory in tact)

Lethargic (unresponsive)

Front 2

Eyes Assessment

Back 2

Check for PERRL(pupils equal round responsive to light)-should constrict

I'm going to take my pen light and flash it into your eyes

Check for symmetry

Check Sclera (should be white)

Check conjuctiva (lower eyelid) should be pink and moist

Note of you see any drainage (what color is it, it it thick)

Does patient where any contact's or glasses ( Do you wear contact's or glasses?)

Front 3

Ear Assessment

Back 3

Check for piercing or gauges (bilaterally, on side left or right)

Are you able to hear me as I speak in a normal tone voice?

Check if patient wears hearing aid (right,left,bilaterally)

I am going to take my pin light and look into your ears to note if you have any drainage, Cerumen(wax), Blood, Pus)

Front 4

Nose Assessment

Back 4

History of Nose (have you had any surgery on your nose?)

Check for Symmetry of Nares

Check for Drainage (is it clear, yellow, thick, blood)

What does it look like when you blow your nose?

Assess patentcy of breathing in and out of Nares(difficulty breathing)

I'm going to place my finger on one side of your nose and I want you to breath in and out to see if you have any difficulty breathing!

Front 5

Mouth Assessment

Back 5

Symmetry of mouth (any drooping can be a sign of seizure)

Can you smile for me?

Do you wear dentures (partials up or bottom, or both)

Do you have all your natural teeth (missing, caps, venieres) (Braces)

As patient talks to you smell any odor -Halitosis

I am going to take my pen light and check the inside of your mouth (mucous membrane are pink and moist, tongue is pink and moist, lips are pink and moist, tongue has a troth due to dehydration)

Note if you see any lesions (cold sores, canker sores)

Front 6

Neck Assessment

Back 6

Check the symmetry

Check if it is soft or supple

Check for Masses

I am going to feel (palpate) your neck and check for any lumps? (Note if is soft and supple also at this point)

Check for swallowing (Trachea is midline)

I am going to hold my finger in the middle of your neck and I want you to swallow for me!

Check carotid pulse unilaterally (not at the same time) (note if strong or weak)

I am going to check the pulse in your neck to see if I can feel it!

Range of Motion (patient has full active range of Motion in neck or passive range of Motion in neck meaning the need assistance)

I want you to turn your head to the left, turn your head to the right, tilt your Head back, tilt your Head forward?

Front 7

Cardiovascular Assessment ❤ Pulse

(Name and Locate)

Back 7

Carotid pulse (strong or weak)

I am going to check your pulse in your neck to see it is there

Brachial pulse (Blood Pressure) Make sure diaphragm is on the loud side and the dial is completely closed before using it. Normal BP is 120/80, Hypertension (systolic 140-159)(diastolic 90-99)

Hypotension (systolic less than 160)(diastolic less than 100)

I am going to take your blood pressure and I want you place it on the desk at an even level!

Apical Pulse (midclavical between 5th and 6th rib for 1 minute normal between 60 to 100 beats per minute) tachycardia (pulse greater than 100 beats per minute) brachycardia( pulse less than 60 beats per minute)

I am going to check your heart rate for 1 minute

Radial Pulse (thing side of wrist) (strong weak or irregular) (30 secs ×2) if you cannot get a pulse the apical pulse will be the next best option

I am going to take your pulse on your wrist for 30 secs!

Femoral Pulse (groin)

I am going to take your pulse in your groin!

Popliteal Pulse (behind the knee)

I am going to take your pulse behind the knee

Posterior Tibial (inside of ankle)

I am going to take your pulse on the inside of your ankle!

Dorsalis Pedis ( top/tip or arch of foot)

I am going to take your pulse on the top of your foot!

Capillary Refil (finger nail) (blanch) (return back to normal less than 3 seconds for circulation)

I am going to apply a little pressure to your thumb and big toe, then I will release

Edema (pitting indentation stays, nonpitting-skin forms back immediately)

Front 8

Thorax/Respiratory Assessment

Back 8

Check the Breast to see if they see symmetrical, any drainage, redness, masses

Check the Axilla(armpit)

I am going to feel (palpate) your breast and armpit to check for any masses

Check smoking history

Do you smoke?

If so, Do you have a cough?

If so, Does anything come up? (productive or nonproductive)

If so, What does it look like?

Ascultate (listen) to lung sounds (posterior in all did quadrants bilateral to compare)

I am going to Ascultate (listen) to your lung sounds, so I want you to take a deep breath in and out (say to all six) Note if you hear wheezing (asthma), rales (fluid), or Rhonchi (pnemonia).

Shortness of Breath

Do you experience periods of shortness of Breath when:

-just sitting there (exasperation)

-engaging in activity

-hyperventilating

-even, shallow, labored( fighting to get breath)

Check Respirations- how many times the chest rises and galls in 1 minute(normal respirations or Upnea between 12-20, Brachypnea-slow less than 12, Tachypnea-fast more than 20)

I am going to check your respirations for 1 minute.

Check O2 Saturations( normal 90-100%, Hypoxic less than 90) (more if you recognize Cyanosis-no oxygen to brain which cause skin to be a bluish purple color)

I am going to place this on your finger to check your O2 saturation

Note if you see patient on medication for respiratory issues (inhaler, nebulizer, oxygen machine)

Front 9

Gastrointestinal/ Genitalurinary

Back 9

Gastrointestinal

Note if Stomach is distended, flat,round

How would you describe your appetite, is it good fair or poor?

When was your last vowel movement?

Describe what it looked like? (Formed, watery, lose, hard)

Where you aware of yourself going to the bathroom or not? Checking for continence or incontinence)

Palpate for any pain in abdomen

I am going to palpate( feel) your abdomen/stomach and when I touch here tell me if you feel any pain

Ascultate Lung sounds in all 4 quadrants

I am going to ascultate( listen) to your bowel sounds in all 4 quadrants for 3-5 minutes so bare with me please! (more if they see active in all 4 quadrants, hyperactive-fast meaning diarrheia, or hypoactive-slow meaning a blockage or constipation in intestines)

Genitalurinary

Check for continence or incontinence

Are you aware or unaware when you urinate(pee)

Frequency (polyuria)

How many times do you go a day?

Characteristic (amber,clear,cloudy,dark tea color,blood in urine)

What does it look like? Nocturia- Do you go often during the night?

Hematuria-Do you have any blood in your urine (pee)?

Dysuria-Do you experience any pain when you urinate(pee)?

Check genitals for any redness, pain, lesions, swelling

Check coccyx area( bottom)

Note if patient has a catheter

Front 10

Integumentary Assessment

Back 10

Note if you see patient has any

Piercings (location)

Tattoos (location)

Birth Marks (location)

Surgical Scars (location)

Moles (location because they can be cancerous)

Bruises (location)

Sore breakdowns (location) (bottom of feet for diabeteics)

Pallor (pale skin may be result of anemia)

Cyanosis (blue skin due to low oxygen)

Check warmth of skin for circulation

Is it cool or warm to touch?

Skin Tears (locate)

Skin Turgor (locate) determine if dehydrated?

Front 11

Musculoskeletal Assesment

Back 11

Assess patients ambulations to check gait (style of walking)

Can you stand up and walk (ambulate) for me? (Note if patient is balanced, favoring one side, has a limp, fast, slow)

Check patients range of Motion in upper and lower extremities

Can you raise your arms above your head for me?

Can you bend your elbow and extend it back down?

Can you rotate your wrist to the left and the right?

Can you wiggle your fingers?

Patient has full active range of Motion in upper extremities

Can you bend your knee, and extend it back down?

Can you lift/stretch your leg in front of you, and lift/extend it behind you?

Can you wiggle your toes?

Patient has full active range of Motion in lower extremities

Assess patients strength

Can you my hands? (equal bilaterally)

Push/Pull

I want you to push against my hand with your hand/feet and I want you to prevent me from moving your hand/foot!

Do you need assistance walking?(ambulating)

-wheelchair

-Cane

-walker

Do you have any pain in your joints?

Front 12

ADL'S (ACTIVITY OF DAILY LIVING) ASSESSMENT

Back 12

Feeding- Are you able to feed yourself?

Bathing- Are you able to bathe yourself?

Grooming- Are you able to comb your hair, put on makeup, brush your teeth?

Transferring- Are you able to move yourself from one location to another?

Ambulating- Are you able to walk by yourself?

Toileting- Are you able to go to the bathroom by yourself?