Head to Toe Assessment Tool

Head-to-Toe Assessment

Initial Survey: Check ABC’s
 

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
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 (bowel sounds 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/client’s adaptation to ostomy)
 

Lower extremities –
Homan’s 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 ā 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.