Head-to-Toe Assessment

Name Date

Date of Birth Gender

Height Weight

Vital Signs

Temp Site BP / Site O2 % on

Pulse regular irregular weak 1+ steady 2+ strong +3 bounding 4+

Resp regular irregular labored moderate shallow deep apnea

Pain 1-10 rating PQRST

IV

Location Date Gauge

Tubing Date Signs of infection?

Fluid(s) Infusing Rate Fluid Remaining

HEENT

Head Eyes Ears

Observation Observation Observation

Palpation PERRLA Palpation

Temporal Pulse Vision Hearing

Subjective Data Subjective Data Subjective Data

Level of Consciousness Nose Neck/Throat

Orientation Observation Observation

Person Palpation Lymph Node Palpation

Place Patentcy Carotid Pulse

Time Sense of Smell Range of Motion

Subjective Data Subjective Data Subjective Data

 THORACIC

Chest Cardiac

Observation Observation

Palpation Apical Pulse

Breath Sounds Heart Sounds

Anterior Posterior AAA Bruit

Subjective Data Subjective Data

GI/ABDOMEN

Quadrant Q1 Q2 Q3 Q4

Observation

Auscultation

Percussion

Palpation

Subjective Data

MUSCULO-SKELETAL

Upper Extremities Lower Extremities

Observation Observation

Strength Strength

Pulses Pulses

Cap Refill Cap Refill

Edema Edema

Subjective Data Subjective Data

INTEGUMENT

Moisture Temperature Color

Subjective Data