Head-to-Toe Assessment - Initial Survey: Check ABCs

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
ApicalRhythm (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 (BS 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/clients
adaptation to ostomy)
Lower extremities
Homans 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 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.