PN

Sem 3

Head to Toe Assessment

Name: ____________________

Wash hands (before and after)
Introduction: who you are; what you are doing; purpose of assessment
Assessment should be completed before administering ANY medications or treatments.
System
Vital Signs

Parameters
Comments/Abnormal Findings
Temperature: (Oral Rectal Tympanic)

Pulse: (Rate, strength, regularity)
Resps: (character, equal expansion)
O2 sat: %
BP: (sitting/standing/laying/site)
Neuro
A & O: Person Place Time

(*additional
Speech: Clear Appropriate Other
assessments
*PERRLA: R ( mm) L ( mm)
needed for
*Check bilateral: Hand strength R ( ) L ( )
CVA patients)
Limb movement (weakness/strength bilaterally)
Pain
Pattern:

Quality:
Radiating/Relieving factors:
Severity (score 0 - 10):
Timing:
Cardiovascular Apical pulse: (rhythm, rate, clarity)

(Vital signs
Skin colour (pink/pale/jaundice/cyanotic
assessment
Skin moisture (dry/moist/diaphoretic)
will be
Skin Temperature (use back of hand)
included)
Cap refill < 3 sec delay (check R & L)
Pulses: dorsalis pedis posterior tibialis
Radial pulses (check bilaterally)
Peripheral Edema (check bilaterally):
Hands: yes no pitting: R ( ) L ( )
Feet: yes no pitting: R ( ) L ( )
Sacrum: yes no pitting: R ( ) L ( )
Respiratory
Anterior (check bilaterally)

Posterior
Clear? R ( ) L ( )
Crackles? R ( ) L ( ) Where:
Wheezes? R ( ) L ( ) Where:
Air flow: Good Poor (diminished)
O2 L/min Nasal cannula Mask
Abdominal
(Inspect and auscultate before palpating)

Bowel sounds: RLQ RUQ LUQ LLQ
Absent Hyperactive Hypoactive
Palpation: Soft Firm Distended
BM? When:
N & V : No Yes
Genitourinary Voiding adequate amts: yes no

Colour:
BR Catheter Bedpan Commode Incont
Skin
Assess mouth (dryness, sores)

(see also CV
Skin for breakdown, redness (bony areas), rashes, lesions
assessment)
Dressings: D & I
IVs
Location:

Site condition: Drsg Skin
Fluid: Rate: ml/hr
*When completed thank the patient, ensure patient safety (bedrails, height), all belongings within reach, call bell close.