Head To Toe Assessment

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Author:
Anonymous
ID:
35457
Filename:
Head To Toe Assessment
Updated:
2010-09-17 22:18:13
Tags:
Head Toe Physical Assessment
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Description:
Nursing Fundamentals practicum Checklist for Head to Toe assessment
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  1. Getting Started
    • Gather Supplies
    • Introduce Self
    • Identify Client
    • Check For Allergies
    • Explain Procedure
    • Wash Hands
    • Provide Privacy
    • Adequate Lighting
  2. Throughout Exam
    • Ability to engage in conversation
    • Facial Expressions
    • Body Positions
    • Hearing response
    • Personal Hygiene
    • Toleration of movement
    • Need for Assistance
    • Pain
  3. Neurological
    • Alert
    • Oriented
    • Hand Grasp Strength
    • Moves all extremeties
    • Clear Speech
    • Complaints of Numbness or tingling
  4. Skin
    • Color
    • Temp
    • Turgor
    • Lesions, rashes, itching
    • Bony Prominences
    • Nails
    • Hair Scalp
    • IV site
  5. Head and Neck
    • Hair distrobution
    • Color of skin
    • Symetry
    • Edema
    • Involuntary muscle movement
    • Mucous membanes (teeth, soft palate response, conjunctiva in eyes)
    • Vision (PERRLA, Gaze fields)
    • Hearing
    • Smell
    • Patency of Nostrils
    • ROM
    • Palpate Lymph nodes
    • Check corotid pulse (one at a time)
  6. Thorax and Lungs
    • Inspect
    • -Use of Oxygen
    • -Breathing pattern
    • -Shape/contour of chest
    • -cough/sputum
    • Auscultate
    • -breath sounds
  7. Cardiovascular
    • Inspect
    • -Visual Pulsations
    • -Neck distention
    • -Auscultation S1 and S2 APETM
    • -Apical pulse (1 minute)
    • Palpation
    • -Radial and Pedal Pulses; grade
    • -Capillary refill
    • -Edema
  8. Abdomen
    • Inspection
    • -visible pulsations; scars
    • -character of stool
    • -contour
    • Auscultate
    • -4 quadrants in a clockwise direction
    • Palpate
    • -soft/firm/pain
  9. Urinary
    • Inspection
    • -Character of Urine (amount, color, clarity, odor)
    • -Foley (patency, character of urine)
  10. Musculoskeletal
    • Inspect
    • -Ambulation
    • -Assistive devices
    • -Gait/Balance/ROM

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