Head to Toe Assessment

Head
Eyes: check sclera, conjunctiva,
accomodation, PERRLA
Mouth: pink, moist, without odor,
teeth alignment, number of teeth,
throat: redness, exudate, lesions

Neck
Alignment: flexibility
Vascular: palpate carotid pulsations,
listen for Carotid bruit
Bruit: swishing sound heard with
stethoscope at carotid artery.
Lymph nodes: palpate for swelling

Chest
Breathing: bilateral sounds,
inspiration and expiration, rales,
rhonchi, crackles
Heart Sounds:S1 and S2= lubb
dubb. Note rate, regularity rhythm
Note AP should be 1:2 ratio

Abdomen
Palpate for tenderness, guarding,
Listen to Bowel Sounds in all 4
quadrants. RU, RL, LU, LL
Note quality of sounds, hypoactive,
hyperactive, without sound

Appendicular Assessment
Arms: check for bilateral alignment,
note grip strength, as well as ability
to release grip
Note capillary refill in fingertips
Legs: Check for bilateral alignment,
note reflexes(Babinski) as well as
strength of flexion and
extension(gas pedal), varicose veins

Skin Color
Note any changes in complexion:
Jaundice
Cyanosis
Darker skinned patients may appear
pale instead of a bluish tint.

Mental Status
Orientation:
Name
Day of week
Date
Who is president
Situation: If other assessments are
negative.

Mental Status-Level of
Consciousness
Alert: aware of situation and
surroundings
Decreased LOC: somewhat awake,
easy to fall into sleep, may or may
not be aware of situation or
surroundings.
Unresponsive: no verbal, or physical
response to stimulation

THE

END