HEAD TO TOE ASSESSMENT

*HEAD TO TOE ASSESSMENT*

EYES
HEAD • Perrla-pupils, equal, round
• Inspect head-size; shape-still; reactive, light, accommodation
upright; symmetric round; eyelids, eyelashes
erect, midline, no lesions-
hard, smooth
1 2 NOSE
• External and internal nose,
airflow
FACE 4 3
• Symmetry, features, MOUTH
expression, skin - sinuses • Check tonsils
- temporal Artery 5 6 • Check tongue
- temporomandibular • Check gums
joint (have client open • Teeth, lips
mouth) • Moist pink mucous membrane

LUNGS
CARDIAC • Inhale, Exhale Phase
• Heart rate • Breath Sounds
• Apical pulse • Equality In Both Lungs
• RR, Depth Character
• Heart Sounds
• Accessory Muscle Use
• LUBB, DUBB
• APTM HANDS
• Check radial pulses
• Check capillary refill
ABDOMEN • Check edema
• Bowel sounds • Check nail beds
• Inspect abdominal area - flat, - Shape
distended, concave, convex - Texture
• Palpate area in little circles - Color marking
along with percuss organs - Cleanliness

LEG FEET
Edema
• Edema
Check pedal pulses
Check capillary refill

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 HEAD TO TOE ASSESSMENT
*HEAD TO TOE ASSESSMENT*

EARS HAIR
• Inspect auricle, tragus, • Thinness or thickness
lobule (note any lesions, • Check Scalp
discolorations, • Assess color
discharges)-
external auditory
1 2 NECK
canal 4 3 • Palpate carotid arteries
• Tympanic • Check carotid pulse
membrane-color,
5 6 • Check lymph node
shape, consistency
and marks 8 7
9 10 BACK
• Percuss for Kidney
• Lung sounds

*ROM
• Check hands
SKIN • Check feet
• Braden Scale • Check legs
• Skin Color-pale, • Check arms
* Check for equal strength
flushed, cyanotic
in extremities
• Skin turgor-hand
or clavicle
• Note any moisture, KEY
redness, edema,
temperature
Pulses
Pressure
Lungs
Cardiac

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