Neuro / Sensory

Orientatio Person, place, time, day/date

n
LOC
Awake, alert, confused, agitated, lethargic,
unresponsive,
Speech
Clear, slurred, verbal, non-verbal, aphasic, expressive,
language barrier
Vision
Glasses, contacts
Hearing
Hard of hearing; L or R, hearing aid; L or R
Pain
Location, intensity of pain (scale), onset, consistency;
on and of
Description; pressure, ache, pull, sharp, dull, heavy,
heat
Head & Neck
Eyes
Clean, PERRLA, drainage; scant, yellow,
Conjunctiva; pink, moist, dry, pale
Sclera; white (normal), pink (infection, irritation)
Ears
Clean, no drainage;
Nose
Clean, drainage; mask or nasal prong; flaring of nostril,
congested;
on oxygen tank
Mouth
Teeth, dentures, moist, dry, pink, pale, cyanotic,
drooping L or R side
Tongue; pink, moist, dry, midline, deviation, difficulty
swallowing
Neck
Distending neck veins, JVD, trach site
Chest / Respirations
Breathing
Even or uneven, shallow, deep, unlabored,
rate/rhythm
Dyspnea,
short of breath, bilateral
cough
productive, non-productive, dry, congested, asthma
Breath sounds Wheezes, rales, ronchi, crackles, sonorous
Shape
WNL, barrel chest, symmetrical,

Heart / Cardiac
Rate/Rhythm Regular, irregular, pulse bpm, blood pressure
Heart sounds,
Pulse
Location, intensity; strong, faint
Incisions
Healing, fresh, pink, swollen, drainage, pacemaker
Dressings
Clean, intact, soaked, bloody

Abdomen / Gastrointestinal
Bowel
Normoactive, hypoactive, hyperactive, positive,
sounds
sounds present

Tenderness
Shape
Incision

Soft, firm
Flat, obese, round, distended, non-distended
Intact, healing, staples intact

Elimination / Genitourinary
Voiding
Consistency, amount, continent, incontinent, odor
Urine
Clarity; clear, cloudy, odor, color; yellowish, pinkish
Stool
Watery, dry, hard, soft, color; brown, green, tarry
Artificial
Colonoscopy bag, indwelling catheter, condom
orifices
catheter

Skin / Integumentary
Color
Pink, pale, yellowish, redness, blue
Temperature Warm, cold
Moisture
Dry, moist,
Turgor
WNL, no tenting
Integrity
Intact, bruises, rashes, redness, irritation, cyanotic,
ulcers

Skeletal / Mobility
Active ROM
Full use of all extremities, assistance, out of bed
Passive ROM
Limited, bed-ridden
Active daily
Independent, dependent, or limited assistance;
living
bathing,
grooming, feeding, toileting, transferring
Ambulation
Walker, cane, wheelchair, no equipment needed
Gait
Steady, unsteady

HEAD TO TOE ASSESSMENT