Head to Toe Assessment

Abdomen- inspect shape, symmetry, visible pulse/peristalsis

Patient: ____________________________________ -Bowel Sounds-all four quadrants? Yes No
* If no, then which quadrant is absent? 1 2 3 4
Neurological -Light Palpation
“State full name & DOB?” Correct Incorrect “Does this hurt anywhere?” Yes No
“Where are you right now?” Correct Incorrect * If yes, where?____________________________________
“Date or president?” Correct Incorrect -Deep Palpation
“Does this hurt anywhere?” Yes No
Review of Systems * If yes, where?____________________________________
“Are you having any pain right now?” Yes No “BM’s: when, consistency, color, “normal” for you?”
*If yes: 1 2 3 4 5 6 7 8 9 10 ________________________________________________
*If yes, where? ______________________________
“How is your appetite?” Good Fair Poor Extremities/pulses- inspect color, temp, appearance
“Any trouble going to the bathroom?” Yes No Carotids Yes No
*If yes “Do you need assistance?” Yes No Brachials Yes No
“Are you having any shortness of breath?” Yes No Radials- equal Yes No
Capillary refill ____________________________________
Vitals “Squeeze my fingers?” (Equal?) Yes No
Blood Pressure: ____________________ Posterior tibial-equal Yes No
Pulse Rate: ________________________ 3-bounding 2-normal 1-weak 0-absent
Pulse Force: 3-bounding 2-normal 1-weak 0-absent Dorsal pedis-equal Yes No
Respirations: ______________________ 3-bounding 2-normal 1-weak 0-absent
Temperature: ______________________ “Push feet down on my hands?” Yes No
“Pull toes up?” Yes No
Head/scalp
Hair distribution even? Yes No Skin
Lesions Yes No Breakdown or bruising? Yes No
Eyes (Pupils) Skin color? Normal Abnormal
Equal? Yes No Edema? Yes No
Round? Yes No * If yes, indicate: 1-mild 2-moderate 3-deep 4-very deep
React to Light? Yes No
Accommodation? Yes No Notes:
Size (in mm) ________
Mouth
Dentures Yes No
*If yes, any problems? _____________________________
Lesions, sores? Yes No

Anterior/Posterior Chest- symmetry, pulsations, shape

Spinous processes straight? Yes No

Lungs
“Take a deep breath for me, in & out please?” (mouth open)
Normal Abnormal
-Breath Sounds- __________________________________
Cough- _________________________________________
Carotids-bruits present Yes No

Heart Exam
-Aortic Normal Abnormal
-Pulmonic Normal Abnormal
-Erb’s Point Normal Abnormal
-Tricuspid Normal Abnormal
-Mitral Normal Abnormal
*Apical pulse 1 min ______________________________