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Head-to-Toe Assessment - Initial Survey: Check ABCs LOC (Awake, alert/lethargic/unresponsive) Orientation (to person, place and time)

Neuro check (PERRLA/Glasgow Coma Scale if appropriate) Skin color (pale/pink/ruddy/cyanotic/dusky) Skin temp (cool/cold/warm/hot) Skin texture (dry/diaphoretic) Skin lesions/pressure or statis ulcers/ecchymoses: color, drainage, odors, LxWxD in cm VS T (include route), P, R, BP/5th VS = PAIN S2S1, Apical-rate, Rhythm (regular/irregular/regularly irregular) Intensity (loud/distant) O2 and Pulse Ox Effort (easy/unlabored) Depth (deep/shallow/blowing)/Auscultation-ant/lat/post * Chest tubes/need for suctioning/advanced skills, i.e. tactile fremitus/diaphragmatic excursion if applicable Upper extremities if IV present note: gauge, solution, rate and infusion pump/controller. Assess IV site for: warmth, redness, edema, drainage or tenderness. Abdomen inspect (round/flat/obese/distended) * Any PEG, G-tube, NG-tube, Dobhoff tube? Auscultate (BS present x 4 quads? rhythm of BS normal/hyper/hypoactive and the intensity high/low-pitched) Palpate (soft/firm/hard/tender to light and deep palpation?) Abdomen (continued) Bowel: Last BM (size/color/consistency/odor) Postop flatus? Incontinence urinary or fecal or both? GU: Void/ Foley/ Suprapubic/Fr and balloon size, amount, color, presence of mucus/sediment, odor. Note patency and describe urine in dependent drainage bag tubing. Ostomy? (note condition of stoma and skin surrounding stoma/contents of ostomy bag-phalange or bag change/clients adaptation to ostomy) Lower extremities Homans sign (negative/positive) - with positive being a bad sign possibly indicative of DVT. Pedal pulses (Dorsalis Pedis/Posterior tibial, compare bilaterally, Grading (0 - +4)/check for edema) pitting (+1 - +4)/nonpitting? Capillary refill (brisk/sluggish-how long, >3 seconds) ROM, Gait Dressings, drains or wounds should be assessed and documented in the order they appear in the assessment i.e. RUE RLE. If a circulation check is done, place that information in the order it was assessed. Circulation Assessment, include: color/warmth/pulse/ capillary refill/movement and always compare bilaterally. Client Education: Include how client learns best, teaching done and client response.


MENTAL STATUS: o Oriented o Person o Place o Time o Date o Alert o Dull Affect

SPEECH o Clear o Other_______________

STIMULUS RESPONSE: o Verbal o Touch o Pain


o Cooperative o Uncooperative o Combative o Anxious o Depressed o Restless o Unresponsive o Confused (explain)___________ o Other (explain)______________

GENERAL: o Syncope o Dizziness o Malaise o Seizures o Memory loss o Insomnia o Other______________________ COMMENTS:


o Symmetrical o Range of motion o Oral mucosa o Pink o Other_______________ o Moist o Dry o Teeth present condition___ o Teeth absent____________

EYES: o Drainage o Pupils o Equal o Unequal o React to light o Accommodate o Sclera o White o Jaundice o Other___________________

o Conjunctiva o Pink o Pale o Other___________________ EARS: o Drainage COMMENTS:

MUSCULOSKELETAL: o Symmetrical muscles o Full ROM o Absence of joint swelling o Full muscle strength o Steady gait o Other______________________ COMMENTS:

RESPIRATORY: Rate_______________ o Effort o Norma; o Shallow o Hyperpnea

o Wheezing o Dyspnea o Apneic periods o Orthopnea o Labored o Painful o Other______________ o Rhythm o Regular o Irregular o Sounds o Equal o Clear o Other COMMENTS:

CARDIOVASCULAR: o Apical pulse o Regular o Irregular o Rate______________

o Jugular Neck Distention o Pain

PERIPHERAL VASCULAR: o Pulses RT LT o Carotid_____________ o Radial______________ o Brachial____________ o Femoral____________ o Popliteal____________ o Posterior tibial_______ o Dorsalis pedis________ o Rhythm o Regular o Irregular o Homans o Pain o Blood pressure o Right arm o Left arm COMMENTS:

GASTROINTESTINAL: o Abdomen o Soft o Distended o Painful o Rigid o Other_________________ o Bowel sounds o URQ o LLQ o LLQ o RLQ o Intake/Appetite o Percentage____________ o Dysphagia o Trouble chewing o Nausea o Vomiting o Weight loss o Weight gain

o Other_________________

Food Intolerances:

BOWEL HABITS: o Frequency____________________ o Diarrhea o Constipation o Date last BM__________________ o Aids for elimination____________ o Color o Black o Bloody o Other________________ COMMENTS:

RENAL/UROLOGICAL: o Urine flow o No problems o Urgency o Incontinent

o Burning o Hesitancy o Dysuria o Hematuria o Frequency o Other_________________ o Appearance/color_______________ COMMENTS:

INTEGUMENTARY: o Coloring o Skin o Pink o Cyanotic o Jaundice o Other_________________ o Texture/Turgor o Dry o Moist o Inelastic o Other_________________

o Nail beds o Pink o Pale o Cyanotic o Capillary blanching__sec o Edema o Absent o Pedal o Sacral COMMENTS