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  • Head-To-Toe Assessment Card

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    Hope Roberson
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    The document outlines the components of a head-to-toe physical assessment, including gathering information on medical history, pain assessment, neurological examination, examination of the head, eyes, ears, nose, and throat, pulmonary, cardiac, abdominal, genitourinary, and skin assessments as well as assessments of the upper and lower extremities.

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    Head-to-toe assessment card

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    The document outlines the components of a head-to-toe physical assessment, including gathering information on medical history, pain assessment, neurological examination, examination of the head, eyes, ears, nose, and throat, pulmonary, cardiac, abdominal, genitourinary, and skin assessments as well as assessments of the upper and lower extremities.

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    © All Rights Reserved
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    14 views1 page

    Head-To-Toe Assessment Card

    Uploaded by

    Hope Roberson
    The document outlines the components of a head-to-toe physical assessment, including gathering information on medical history, pain assessment, neurological examination, examination of the head, eyes, ears, nose, and throat, pulmonary, cardiac, abdominal, genitourinary, and skin assessments as well as assessments of the upper and lower extremities.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    Head-to-toe assessment

    Medical hx: allergies (medication, food, environmental factors), diagnosed medical problems,
    surgical hx, substance use (alcohol, tobacco, marajuana, illicit substances)

    Pain: PQRSTU

    Neuro: difficulty swallowing or trouble with speech, orientation (person, place, time, situation),
    LOC, symmetry of facial features, PERRL (direct and consensual)

    HEENT: changes to vision or hearing, external eye structures (conjunctiva - have pt. pull down
    lower lids, sclera, cornea - shine pen light laterally in both eyes), oral mucosa (have pt. pull down
    lower lip; lips, buccal mucosa, gums), teeth (have pt. open mouth; number, color, restoration,
    alignment), hearing

    Pulmonary: SOB or difficulty breathing, chest (symmetry, shape, inspiratory/expiratory effort),


    position of trachea, breath sounds (anterior - 4, posterior - 6, lateral - 2; one full respiration cycle)

    Cardiac: chest pain or heart racing, apical site for 30 secs

    Abdominal: last BM and abd pain, contour of abd, BS in all 4 quadrants, palpate over all 4
    quadrants

    GU: pain/burning with urination or change in frequency

    Upper extremities: numbness/tingling or pain, extremities (palpate down both arms), radial
    pulses, cap refill, ROM/strength with hand grasp

    Lower extremities: numbness/tingling or pain, extremities (palpate down both legs), DP/PT
    pulses, cap refill, ROM/strength with flexion and extension

    Skin: changes to skin or noticeable odor, variations, breakdown, masses, lesions, unusual
    scars/moles, edema, temperature, turgor, odor

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