Head To Toe Assessment Checklist Client Initials Vital Signs Time T P R B/P Manual/Electric Location Body Position Upper

Extremities Skin Color Skin Temp Turgor(Chest) Radial Pulses Capillary refill Handgrip Movement ROM Lower Extremities Skin Color Skin Temp Pedal Pulses Capillary refill Movement ROM Hohman s Sign Oxygen Oximetry Liters/Minute Room Air Nasal Cannula Mask

IV/Saline Loc Solution Rate Site Redness Irritation Edema Pain Pain Location Duration Scale (1 10) Intervention Evaluation (within 30 minutes)

Mental Status Alert Person Place Time Apical Pulse Rate Regular Regular Irregularity Irregular Irregularity Elimination Voiding freely Continent/incontinent Foley Patent Color Clarity BM Continent/incontinent Color Consistency Amount Pupils Left Right P E R R L A Breath Sounds Anterior/Posterior L Upper Middle Lower Inspiratory/Expiratory Dressing Location Clean Dry Intact Drainage Color Amount Odor Consistency Mucous Membranes Moist Pink Abdomen Soft Round

Non Tender LUQ RUQ LLQ RLQ Miscellaneous Pt in bed Low position Siderails up Call light within reach Special equipment