Head to toe assessment

Before entering clients room check for order of assessment, and allergies

Enter room: Introduce yourself, provide privacy, Provide hand hygiene

Identify client, verify allergies, explain procedure, ask about pain

Ask orientation questions Do you know why you’re here? What season is it? What day is it?

* Raise bed*. start physical assessment: Palpate and inspect head, ears, eyes. Assess pupil reaction, assess pupil accommodation and have Client follow pen (6 fields of cardinal gaze). Have client stare in distant and shift focus from far to near checking accommodation of pupils. Check inside of mouth and nose for a moist mucosa. Palpate carotid artery for symmetry

Assess vital signs: Temperature, spO2, blood pressure, radial pulse, and respirations, assess grip strength of hands and push and pull techniques.

Assess lung sounds and heart sounds anteriorly and posteriorly. Assess skin of chest and back

Check capillary reflexes in fingers and assess skin of extremities.

Inspect abdomen first, then listen to bowel sounds starting from right lower quadrant and working around. Next palpate abdomen from right lower quadrant.

Ask about last bowel movement? What it looked like? Ask about last urination and status of urine.

Check Lower extremities for symmetry and edema, assess capillary refill in toes and palpate pulses: Posterior tibial , Dorsalis pedis, find femoral pulse and popliteal.

Ask about pain again. Lower bed* Ask if client needs anything? Provide hand hygiene.