HEAD TO TOE ASSESSMENT

General Appearance [inspection]

Gender, race, age Abdomen [inspect, auscultate, palpate, Abnormals: hernias distention
Signs of distress (angry, pain, anxiety) percuss] hypo/hyperactive bowel sounds
Affect and mood Know landmarks for each quad striae
Orientation x3? (person, place, time), LOC palpable masses
Speech pattern Active bowel sounds (every 5-35 sec.) pulsing masses
Body type (obese, frail, muscular) Soft, non-tender absent bowel sounds (2-5 min.)
Posture, gait, movements
Hygiene and grooming
Vascular system [inspect, ausculate, palpate] Abnormals: bruit bruising
Inspect for bounding or distended absent/weak, thready
pulse
Skin, hair and nails [inspect and palpate] Abnormals: diaphoresis petechiae arteries & edema delayed capillary refill (>3sec.)
Can by done while assessing other cyanosis edema Palpate for pulse, palpate edema phlebitis
body parts or by itself pallor bruising Auscultate for abnormals
skin should be intact, dry, smooth jaundice erythema
color congruent for race? excessive pigmentation
mucous membranes should be moist eczema Genitals and rectal area [inspect, palpate] Abnormals: hemorrhoids discharge
and pink induration voiding sufficient quantity? Lesions/chancres
turgor (elasticity) should be immediate ridged or broken nails foley present? Rectocele/cystocele
pressure areas? last BM?
Nails smooth

Head [inspect and palpate] Musculoskeletal system [inspect, palpate] Abnormals: kyphosis lordosis
Should be upright and still Abnormals: paralysis ROM Scoliosis
Symmetrical facial features asymmetrical features reflexes osteoporosis
Eyes – sclera white, pupil clear, lesions/sores in mouth/ears decreased ROM atrophy
smooth equal movement, drainage/matting in eye hyper/hypotonicity
PERRLA, glaucoma cataracts
ears – symmetrical, no drainage strabismus nystagmus Other: any tubes present (IV, foley, oxygen, etc)?
mouth – membranes pink and moist, ptosis exophthalmos Dressings? Describe type and any drainage present
palate intact, no swelling in throat congunctivitis caries Incisions? Intact with staples, color of surrounding skin, etc.
neck – soft, no swollen lymph nodes varicosities
carotid arteries palpable
dentition CRANIAL NERVE ASSESSMENT

I Identify familiar odors

Chest and lungs [inspect, auscultate, palpate] II Visual Acuity
Symmetrical expansion with Abnormals: adventitious sounds: III Pupillary response
respiration crackles (rales) rhonchi IV Follow your finger w/o moving head
Lung sounds – vesicular, wheezes pleural V Assess for sharp, dull sensations on face, have patient hold mouth open
broncho-vesicular,bronchial S3 or S4 VI Follow your finger w/o moving head
Heart sounds – S1 & S2 (lub dub) murmers thrill VII Have patient smile, differentiate between sweet and sour
PMI – point of maximal impulse (apex) dysrythmia VIII Hearing: snap fingers close to ears
cough Balance: feet together, arms at sides with eyes closed for 5 sec.
Ease and depth of respirations clubbed fingers IX Have patient swallow and say “Ahh”
Peripheral pulses X Elicit gag reflex
XI Have patient shrug shoulders
XII Have patient stick out tongue and move from side to side