Department of Nursing Health Assessment

Head-to-Toe Assessment Checklist

Student: __________________________________________ Date: _______________________ Grade:_________ Pt s Review clients record & printed history. Introduce self, explain procedure, inquire if client needs to use the bathroom, provide for privacy, & if member of the opposite sex or examination of personal areas obtain second health care member. Perform hand hygiene. Assess the overall appearance of the client including level of consciousness, mental status, mood/affect, personal hygiene, & oriented to person, place and/or time (1) Assess for any limitations or deficits to clients hearing or sight (1) Assess clients pain level and medicate if appropriate Obtain baseline vital signs Perform PERRLA & inquire if there are any changes in vision, hearing, smell & taste. (This quickly assesses cranial nerves and investigate & evaluate further if any abnormalities) (1) Assess head and face for symmetry and any gross anomalies Palpate face & head Assess clients tongue looking for moistness, pink (no cyanosis) , & midline (1) Palpate carotids one at a time & rationale (1) Auscultate carotids using bell & bronchial sounds using diaphragm Inspect skin color, nail bed angles, capillary refill, turgor, edema, temperature and moisture of upper extremities (1) Palpate radial, & femoral pulses (1) Assess motor skills for strength, arms, & handgrip (1) Inspect chest for symmetry & gross anomalies (1) Assess heart sounds (5 places with bell and diaphragm) Count apical pulse Auscultate lung sounds anterior, lateral, and posterior (2) Inspect abdomen Auscultate 4 quadrants of abdomen (1) Assess urination (color, frequency, & dysuria) (1) Assess for last BM (frequency, color, & moisture) Assess lower extremities for skin color, capillary refill, edema, temperature and moisture (1) Assess peripheral pulses (PT & DP) (1) Check for Homans sign (1) Assess motor skills for strength in legs (push in 4 directions) Assess overall skin integrity Assess any wounds, surgical incisions, & IV sites (1) Assess safety issues 4

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Instructors Signature: ___________________________________________ Date: ____________

Department of Nursing Health Assessment

Document findings 3

Instructors Signature: ___________________________________________ Date: ____________