Pines City Colleges

College of Nursing

Head to Toe Physical Assessment

Students name: __________________________
Client Name: ____________________________ Room Number: ______

Medical Dx:
__________________________________________________________________________________________
_____________________________________________________________________________________

VITAL SIGNS

Temperature: ________ ºC
Results Pulse Rate: ________ bpm
Respiration: _________cpm
BP: _____________mmHg
GENERAL SURVEY

How does the client Age: _____ Gender: Male Female Body Build: Ectomorph
look? Mesomorph
Endomorph
Height: _____ cm Weight: _____ kg BMI: _____

Grooming: Well-groomed Poorly Groomed

Facial Expression: Anxious Happy Sad Angry Others:________

NEUROLOGICAL

(LOC) Level of Alert Awake Lethargic Obtundent Stupor Comatose

Consciousness
M V E GCS score : ________ Deficit : ____________
Orientation Oriented : Person Place Date Time
Attention span: able to concentrate as evidenced by answering the questions
appropriately YES NO
Pain Character ______ Onset _____ Location_____ Duration____ Severity______ Pattern _______
Associated Factors _________ (COLDSPA)

Provoking factors___________ Quality_______ Radiation ________ Severity________ Time______

Head The head of the client is round, normocephalic and symmetrical YES NO___________

There are no nodules or massess and depressions when palpated YES NO

Skull Fontanels? Present Absent
Eyes Unaided sight Glasses Contact Lens Implants Prosthesis
Snellen 20/ _______ Blind______
Extraocular Muscles Intact Not intact Why? ___________
Visual fields Intact Not intact Why?_____________
Pupils Pupils Equally Round Reactive to Light Accomodation (PERLA)
Sluggish Brisk Nonreactive to light Consensual

Pupil size before light: _______mm

Pupil size after light:________mm
Color:__________
Cornea Clarity and texture : Transparent Smooth Shiny

Color :__________________

Corneal Sensitivity : Blinks when the cornea is touched through a cotton wisp from the back
YES NO
Ears Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen
Drainage
The auricles are symmetrical and has the same color with the facial skin , aligned with the
outer canthus of the eye,mobile, firm and tender YES NO Why? __________
pinna recoils when folded

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Nose and Sinus The nose is symmetrical , straight and uniform in color YES NO
Presence of discharhe or flaring YES NO
tenderness and lession upon palpation YES NO
Mouth The lips are uniformly pink ;moist, symmetric and have smooth texture,able to purse lip
when asked to whistle YES NO

Teeth and gums Discoloration of enamels retraction of the gums pinkish in color
Buccal mucosa is unifromly pink ,moist ,soft ,glistening and with elastic texture YES NO
The tounge is centrally positioned,pink,moist and slightly rough,presence of thin whitish
coating YES NO
Smooth palates are light pink and smooth while the hard palate has more irregular texture
The uvula is positioned in the midline of the soft palate YES NO
Gag Reflex? Present Absent
Neck The neck muscles are equal in size, coordinated,smooth head movement with no
doscomfort YES NO
Lymphnodes are : Palpable Not palpable
Trachea is placed midline of the anterior neck YES NO
thyroid gland is not visible on inspection and the glands ascend during swallowing but are
not visible YES NO
RESPIRATORY

Respirations Regular Irregular Unlabored Labored Symmetrical Asymmetrical

c
c Nasa flaring Sternal cretraction c
Intercostal c
retraction c
Chest cc chest wallcis intact
The c withc no tenderness c cand masses c YES NO c
There
c is a full and symmetric
c expansion and
c the thumbs separate 2-3 cm during deep
inspiration when assessing the respiratory excursion YES NO
Pigeon Chest
Barrel Chest
Funnel Chest
Spine The spine is vertically aligned YES NO Kyphosi Lordosis Scoliosis
The right and left shoulders and hips are of the same height YES NO
Lung sounds Clear LUL RUL LLL RLL RML Anterior Posterior
c c c C c c c c
Adventitious
c c Lung csounds:c c c c c
Wheezes location ___________________
Rales/Crackles Location _______________
Rhonchi Location_______________________

Do lung sounds improve with cough and deep breath? YES NO

Cough None Nonproductive Dry Moist Productive
c c
Sputum:amount____________ cColor_____________
c c Frequency________________
Oxygen Room air
c c Pulse ox______ c O2 at ______L/min
c c
Nasal Cannula Mask Tent CPAP BIPAP
c c ml_____Frequency______hold
Incentive Spirometer (IS): c c c
for____seconds # of times______
Respiratory
c
Medication________________
c c c c
Treatments
CARDIOVASCULAR

Skin/Mucous Pink Pale Cyanotic Jaundice Ruddy Flushed Diaphoretic

c c c c c c c
Membranes
c c c c c c c
Radial and Pedal Radial: Palpable (L/R)______________ Absent(L/R)____________
Pedal: (DP PT) Palpable(L/R)_______________ Absent(L/R)______________
Pulses
Apical Radial Pulses Apical:______ bpm
Radial:_______bpm Pulse Deficit :_______ bpm
Carotid Pulses Right Left Thrill Bruit
Capillary Refill _____ sec (Blanch test)
Jugular Neck veins Not Visible Visible
c
Edema Absent Present:Location Ansarca Pitting Non Pitting
c c
Calf Tenderness Absent Denies Positive homan’s sign R L calf size R___ L___
c c
Heart Rhythm / There were no visible pulsations on the oartic and pulmonic areas YES NO
No presence of heaves and lifts YES NO
Sounds – S1S2
Regular Irregular Murmur Extra sound Strong Faint Muffled
c
Telemetry: c Rhythm_________________
c c Pacemaker c Defibrillator:c c
Location
IV Solution:________________________
c c c Ratec:______ml/hr c Pump:______
c c
Site location (be specific):________________________________________
Site appearance: Clear Edema Erythema Tender Pallor
Dialysis access: Typec ____________
c c
Thrill Bruit c Location:______________
c
Appearance:_______________
c c c c c
ALLERGIES :
BLOOD GLUCOSE :
GASTROINTESTINAL

Oral Teeth Dentures Caries Dysphagia

c
Mucuous c
Membranes: ccIntact cc Moist
cDry c
Pale cc
Leukoplakia cc
c
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c
Abdomen: Inspect The abdomen has an Unblemished Skin And uniform in color YES NO
The abdomen has a Symmetric Contour YES NO
Auscultate Percuss
Soft Round Flat Scaphoid Obese Firm Hard
Palpate c c c
distention:__________________ c c
Tender:_______ c c
Location:___________________
c c c c c c c
Bowel Sounds RLQ RUQ LUQ LLQ
cNormoactive
c cHyperactive
c Hypoactive Absent
cc
None_____ c
cType of tube_________
c c c Patent Nonpatent
c
NG/GT/JT
Suction:
c low_________c high__________c cColor of drainage_________________
c c
Bowel Movements Continent Incontinent c c
c BM:___________ c Color__________ Consistency _____________ Ostomy_____________
last
Nutrition c
Diet___________ c
% eaten Breaksfast______ Lunch _______ NPO? Why______________?
Self-feed Needs Assistance
c
Thickened c
Liquids: Honey Nectar ___________ Pudding__________ Tube Feeding____________
GENITOURINARY c c

Urine Continent Incontinent

c
Catheter c
Type__________________ Patent______________ Nonpatent_______________
Color______________
c c Clear Cloudy Sediment Burning Frequency
c
PO/oral/Tube Feed intake_____________ IV intake____________ Urine Output__________
Intake and Output
other___________ c
Fluid restriction? Total I&O+/- ______________
Genitalia Male Female Discharges______________
LMP_______________________ Post-partum__________________
MUSCULOSKELETAL

Extremities The extremities are symmetrical in size and length YES Pocomelia
upper and lower NO Amelia
Gross motor and Walking gait: has upright posture and steady gait with opposing arm swing unaided and
maintaining balance YES NO
Balance
Standing on one foot with eyes closed:Maintained stance for atleast 5 seconds YES NO
Heel toe walking: maintains a heel to toe walking along a straight line YES NO
Toe or heel walking: able to walk several steps in toes/heels YES NO
Fine Motor Test UPPER EXTREMITY
Finger to nose test: repeatedly and rythmically touches the nose
alternating supination and pronation of the hands on knees: can alternately supinate and
pronate hands at rapid pace YES NO
Finger to nose and to the nurses finger: perform with coordinating and rapidity YES NO
Finger to fingers: perform with accuracy and rapidity YES NO
Fingers to thumb: rapidly touches each finger to the thumb with each hand YES NO
LOWER EXTREMITY
Pain Sensation: able to discriminate between sharp and dull sensation when touched
YES NO
Mobility ADLs independent or assisted with __________________________________________________?
Turn self and right Sits Independently Dangles Stands Independently
Walks independently
Ambulatory assisstance: Gait belt Cane Walker
Crutches Braces Wheelchair
Walks:Distance_____________ Frequency____________ Tolerance__________ PT/OT/RNA_____
Muscle The muscleare not palpable ,no tremors
Firm, smooth,coordinated movements
MMT(muscle strength)
None Cast Brace Splint Location: Traction-type : Traction wt:
Bones There was no presence of bone deformities,tenderness and swelling YES NO
Circulation Color__________ Motion___________ Sensation___________ Temperature_____________
RA________ LA_______ RL________ LL_________ Antiembolitic hose:Knee/Thigh
Contractures Not present Present ______________which extremity?
______________ What % decreased?
Amputation NO YES Location:______________________________
ROM AROM AAROM PROM CPM limited Location:__________
Risk for Falls NO YES WHY?
INTEGUMENTARY

Appearance Intact: color____________ Pallo r Rash Bruise Lesion Scar

Location:______________
Turgor:________Seconds Site:_____________
Skin Warm Hot Cool Cold Dry Moist
Wound Dressing None Surgicalsite-Location Well approximated Sutures Staples STERIS trips
Dressing : Dry /Intact Non-Intact Change: YES NO
Pressure Ulcers
Drainage: Color________________ Amount:______________ Odor:_____________
Wound Appearance__________ Drain type: ____________ Amount:___________
Stage: _________ Location_________ Size___________ Tunneling __________
Eschar___________ Slough ___________

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PSYCHOSOCIAL

Behavior Cooperative Uncooperative Pleasant Withdrawn Combative

Other:_________
Restraints None Chemical Physical:__________ Type_____________ Location__________
(CMST)Color_________,Motion____________,Sensation_________,Temperature__________
Of extremity RA_________ LA ________ RL________ LL__________
Frequency Checked________________
Language Spoken __________ Speak Understands other_____________________
Intepreter________

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