Head-to-Toe Assessment

Initial Interactions:
• Provide Privacy as needed
• Introduce yourself to the client.
• Perform hand hygiene and put on appropriate PPE if indicated.
• Verify the client identification. - Name and DOB
• Determine whether the client has allergies. (ask about allergies and reactions)
• Provide the client education (explain to the client what you are going to do)

General Survey:
• Determine the level of orientation (person, place, and time).
• Assess the client’s overall appearance (hygiene, grooming, and dress). Is the client dressed appropriately for the season? Note odors.

Skin Examination:
• Inspect the client's skin color for cyanosis, pallor, jaundice, and erythema. (what is visible, no clothing needs to be moved or removed, don't forget fingernails)
• Inspect the client's head and scalp for color, hair distribution, and lesions. Inspect for infestations.
• Pinch the client's skin over the clavicle to check skin turgor.

Eye Examination:
• Inspect each iris and pupil. Shine a light onto each pupil and note the response. PERRLA (pupils, equal, round, reactive to light, and accommodation). Note if they are cloudy.
• Check for extraocular movement (six cardinal fields of gaze). Up/right, right, down/right, down/left, left, and up/left.

Respiratory Examination:
• Use the diaphragm of the stethoscope to auscultate over all lung fields.
• Begin auscultating above the clavicle of the client's chest from side to side using a zigzag pattern.
• Ask the client to take slow, deep breaths every time the stethoscope is moved. Are crackles or wheezes present?

Cardiovascular Examination:
• Auscultate over five cardiac landmarks in a "Z" pattern.
• Auscultate over the mitral valve for one minute (exact location as PMI). Is the client's heart rate within the expected reference range of 60 to 100/min? Is the client's heart rate regular in rhythm?
• Palpate bilateral radial pulses (note strength and if they are equal)
• Check capillary refill
• Palpate for edema in bilateral lower extremities (note: no edema - 4+mm of pitting)

Abdominal Examination:
• Ask the client if they are experiencing abdominal pain. Note the location, onset, and frequency.
• Auscultate bowel sounds in all four quadrants. Are bowel sounds present?
• Palpate all four abdominal quadrants. Are they tender or firm?

Musculoskeletal Examination:
• Observe the client's gait and balance (tiptoe and heels).
• Test muscle strength of all limbs.
• Test the range of motion of all limbs. Does the client experience pain with movement?

Concluding Steps:
•Document the relevant information in the client's medical record.

•Hand client call light

•Recap findings of the exam with the client

•Gel out