Head to Toe Assessment

Name of Patient: Pt. XY Sex: FEMALE Age: 44 years old Weight: 62 kg

Temp.: 36.6°C Pulse Rate: 90 bpm Resp. Rate: 20cpm BP: 120/80mmHg

EENT Assess eyes, ears, and nose throat for abnormality [] no problem
[ ] impaired vision [ ] blind [ ] Pain [ ] Reddened [ ] drainage []
Lesion seen [ ] gums [ ] hard of hearing [ ] deaf
[] burning [ ] Edema
RESPIRATORY Assessment respiration, rate, rhythm, depth, pattern, breathe sounds, comfort []
no problem
[ ] asymmetric [ ] tachypnea [ ] apnea [ ] rales [ ] cough [ ] barrel chest []
bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing [ ] pain[ ] cyanotic
CARDIO VASCULAR Assessment heart sounds, rate rhythm, pulse, blood pressure, circulation, fluid retention,
comfort [] no problem
[ ] arrhythmias [ ] tachypnea [ ] numbness[ ] diminished pulse [ ] edema []
fatigue [ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] pain
GASTROINTESTINAL TRACT Assessment abdomen, bowel habits, swallowing, bowel sound, comfort
[] no problem
[ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain

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GENITO- URINARY TRACT and GYNE Assess urine freq., control, color, odor, comfort, gyne-bleeding,
discharge [] no problem
[ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia
NEURO Assessment motor function, sensation, LOC, strength, grip, gait, coordination, orientation, speech.
[] no problem
[ ] paralysis [ ] stupor [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose []
vertigo [ ] tremors [ ] confuse [ ] vision [ ] grip
MUSCULOSKELETAL and SKIN assess mobility, motion, galt, alignment, joint function, skin color, texture,
turgor, integrity [] no problem
[ ] appliance [ ] flushed [ ] cool [ ] drainage [ ] petechiae [ ] ecchymosis []
rash [ ] lesion [ ] prosthesis [ ] stiffnes
[ ] atrophy [ ] deformity [ ] poor turgor [ ] hot [ ] diaphoretic []
skin color [ ] moist [ ] wound
[ ] swelling [ ] itching [ ] pain

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