Head to Toe Assessment Checkoff
Quiz yourself by thinking what should be in
each of the black spaces below before clicking
on it to display the answer.
Help!
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| NEURO/SENSORY - LOC | Alert & Oriented X ________
1)Person 2)Place 3)Time 4)Situation
Lethargic/Drowsy/Confused/Forgetful/Unresponsive
Sensations WNL
Other ______________________
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| SPEECH/PUPILS/COMMUNICATION | Clear/Understandable/Slurred/Nonverbal/Aphasia
PERRL (L)___ (R)___
Coherent Conversation/Able to Grasp Ideas/Answers Questions
Appropriately/Follows Instructions
Other Obs.______________________
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| VISION/HEARING | Vision WNL/Vision Impaired ___________
Hearing WNL/Hearing Impaired_____________
Other Obs._________________________
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| PAIN | Pain Level _______ Location ________________
Intervention ___________________
Relief-Post Intervention Pain Level ______
Other Obs._______________________
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| CARDIOVASCULAR | Heart Rate ____ Regular Irregular
B/P ____/_____
Pulses-Present/Absent/Strong/Weak
RRP-P/A/S/W LRP-P/A/S/W RPP-P/A/S/W LPP-P/A/S/W
Nail Beds Pink CRT </> 3 sec
Edema-Pitting Loc/Rating
Non-Pitting Loc/Rating
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| RESPIRATORY | Respiration Rate ___ Regular/Even/Unlabored/Labored/Shallow/Rapid
O2 Sat ___%
SOB (described)
Breath Sounds & Loc - Clear/Equal,
Rhonchi,Wheezes/Crackles
Decreased or Diminished
Cough Present - Y/N
Productive/NonProductive Sputum____
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| GASTROINESTINAL | Bowel Sounds: WNL(ActiveX4)
Hypoactive/Hyperactive/Absent
Abdomen: Soft/Firm/Hard/Distended/Tender
LBM (described) ___________
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| DIET | NPO/(diet) _________
Tolerates Well/Nausea/Vomiting(describe
emesis)
Dysphagia - Aspiration Precautions
Tube Feeding ______ml/hr
% of meals (B)_____(L)_____(D)______
Adequate/Inadequate Intake
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| RENAL/URINARY | Voiding - Without Complaints/Dysuria/Frequency/Burning
Continent/Incontinent
Adequate/Inadequate Output
Catheter Type ________ Patent&Draining _____
Color_____ Clarity_______ Sediment
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| MUSCULOSKELETAL (1st card) | MAE
Activity: Tolerates Well/Fatigue
Activity: Amb per Self/Amb w/assist X____
Transfers per Self/Tranfers w/assist X___
Gait: Steady/Unsteady
Assistive Devices___
Muscle Tone Normal/Fair/Poor/Flaccid
RUE/RLE/LUE/LLE
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| MUSCULOSKELETAL (2nd card) | Movement(normal/limited)-RUE/RLE/LUE/LLE
Strength(strong or weak)-RUE/RLE/LUE/LLE
ROM: Full/Limited/Passive (describe)
Immobile (describe)
ADL’s Independent/Total/Assist
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| SKIN | Color - Pale/Pink/Ruddy/Grey/Jaundice/Cyanosis
Skin Turgor - Normal/Sluggish/Loose
Skin - Warm/Dry/Cool/Diaphoretic
Skin Condition - Fragile/Thin/Intact/Impaired
Mucus Membranes - Moist/Pink/Intact
Redness/Rash/Wounds
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| PSYCHOSOCIAL | Cooperative/Uncooperative
Behavior Appropriate/Inappropriate
Coping Well/Depression/Anxious
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| PRIOR TO ENTERING ROOM - WHAT DO YOU DO? | Gather equipment needed for assessment
a.Stethoscope
b.Appropriate sized blood pressure cuff
c.Pulse Oximeter
d.Penlite
e.Thermometer
f.Gloves
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| UPON ENTERING ROOM - WHAT DO YOU DO? | a.**Perform hand hygiene
b.Identify self
c.**Identify patient
d.**Verify Allergies
e.Assure privacy
f.**Explain what is about to occur
g.Allow for patient questions
h.Raise bed to comfortable working height
i.Don gloves
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| PRIOR TO LEAVING THE ROOM - WHAT DO YOU DO? | 1.Check equip:
a.IV-solution/rate/site
b.O2-setting/type
c.Drains(including foley)
2.Survey envir. for safety
3.Reposition pt
4.Lowerbed
5.Raise approp. rails
6.Call light/belongings in reach
7.**Hand Hygiene
8.Gather/Remove equipment
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Created by:
prich57
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