Head-to-Toe Assessment

Start General

Hand hygiene; Introduce self; Identify client using 2 identifiers; Explain procedure; Provide privacy; Assist client to comfortable position; Raise bed to appropriate working height; Positive nonverbal communication; Eye contact; Explain what you are doing before you do it

Vital Signs

Allergies; Pertinent medical history; Family medical history; Surgical history; Current alcohol/drug use; Obtain and report temperature; Obtain and report manual pulse; Obtain and report respirations (30 sec × 2); Obtain and report BP; Pain/discomfort 0-10; OLDCARTS: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatment tried, Severity; Determine priority focused assessment: Neurological, Cardiovascular, Respiratory, GI, GU, Musculoskeletal

Assessment: Neurological, Head, Neck, and Face

Orientation: Name, DOB, Location, Who drove you here, Today's date, Why are you being seen today; General survey of scalp/head; Head symmetry; Facial symmetry; Smile; Frown; Raise eyebrows; Puff cheeks; Eyes: PERRLA, Cardinal fields; General survey of ears and nose; Mouth: Buccal mucosa, Teeth, Gums, Tongue, Floor of mouth, Palate, Uvula; Observe swallowing; Neck ROM: Flexion, Extension, Hyperextension; Ask at least 1 question about scalp, eyes, ears, nose, mouth

Respiratory: Anterior and Posterior

Expose skin if possible; Posterior: Inspect symmetry, respiratory effort, accessory muscle use, skin characteristics; Auscultate all 18 posterior lung fields and compare side-to-side; Anterior: Inspect symmetry, respiratory effort, skin characteristics; Auscultate all 12 anterior lung fields and compare side-to-side; Ask at least 2: Respiratory history, Breathing changes, Difficulty breathing lying down, Cough, Shortness of breath

Heart

Auscultate APETM with diaphragm: Aortic, Pulmonic, Erb's Point, Tricuspid, Mitral; Name valve and heart sounds while assessing; Ask at least 2: Shortness of breath with exertion, Chest pain, Easily fatigued

Upper Extremities

Capillary refill all 10 fingertips; Skin integrity; Bilateral hand grips; Arm temperature using back of hand; Bilateral radial pulses simultaneously; Skin turgor; Assess numbness/tingling; Shoulder flexion; Shoulder extension; Ask at least 2: Swelling, Pain, ROM issues

Abdomen

Inspect: Contour, Pulsations, Skin integrity; Auscultate bowel sounds in all 4 quadrants BEFORE palpation; Palpate all quadrants lightly; Assess for pain/tenderness; Ask GI questions: Bowel pattern, Last bowel movement, Other GI concerns

Lower Extremities

Leg skin integrity; Pretibial edema; Capillary refill all 10 toes; Leg temperature using back of hand; Bilateral dorsalis pedis pulses simultaneously; Push/pull foot strength; Heel skin integrity; Between toes skin integrity; Assess numbness/tingling; Knee flexion; Knee extension; Ask at least 2: Pain with ambulation, Extremity pain, ROM issues, Changes in hair growth

End General

Update patient on plan of care before leaving; Bed lowest position; Side rails up; Call light within reach; General survey of room/environment safety (clutter free, clear path, IV poles/tubing, oxygen tubing); Hand hygiene before leaving room