Head-To-Toe Checklist BEAUTIFUL NURSING LLC

INTRODUCTION
Wash Hands
Introduction: Introduce Self and Purpose of HTT VITALS: _____HR, _____BP, _____Temp,
Identity Client (Name, DOB against Wristband/MAR) _____RR, ____02, _____Pain
Orientation: Person, Place, Time, Situation
HEAD
Assess Skin (C/D/I: Clean, Dry, Intact) and Color
Oral Mucosa, Gums, Tongue
Pupils (PERRLA) and hearing check
Neck Veins: place pt at 45 degree angle. Flat Veins=Normal, Distended=Fluid Overload
CARDIOVASCULAR
Assess Skin (turgor, C/D/I)
Auscultate Heart at Apical Pulse for 1 Minute (5th intercostal of midclavicular line). Note: rate, rhythm, regularity.
PULMONARY
Assess Skin (C/D/I)
Auscultate Anterior/Posterior Lung Sounds in S Pattern. Ask patient o breathe in slowly through mouth. Note: depth,
rate, and sounds.
Note accessory muscle and oxygen use.
UPPER AND LOWER EXTREMITIES
Assess Skin (C/D/I) Cap refill: on fingers and toes
Check for Peripheral Edema Sensation: hands and feet
Bilateral Pulse: radial, dorsalis pedis and posterior tibial Check all BONY prominences for signs
Bilateral Strength Check of a pressure ulcer
GI
Assess Skin (C/D/I)
Auscultate bowel sounds BEFORE palpation. (RLQ, RUQ, LUQ, LLQ)
Palpate Abdomen (check for distention or pain)
Check umbilicus
EQUIPMENT
Mobility Check: Adapative Devices, Gait, Transferability
IV Site Assessment
Any Other Equipment (Scd's, Braces, Etc)
CLOSURE
Let patient know you finished and give call light Dispose soiled linens, clean room
Offer bed pan or assistance to bathroom Clean equipment used, chart information, and use hand hygiene
 CODE STATUS
DNR: Do Not Resucitate
DNI: Do Not Intubate
Full Code: Do All Resucitation Measures!

DX: Diagnosis. Why is the patient here?

DOA: Date of Admittance. What day did they arrive in the hospital?

DIET
Examples:
Full Diet: No Dietary Restrictions
NPO (nothing by mouth)
Clear Liquids: transparent liquids like: water, tea, broth, popsicles, Jello.
Full Liquid: any liquids like: ice cream, pudding, fruit juices
⬇️
Cardiac Diet: Sodium, ⬆️ ⬆️
Cholesterol, Fiber like: skim milk, low sodium tomato juice and soup, low fat dressing.

ACTIVITY
Independent: Patient can do all activities without help.
Assist x1: One person is needed to assist patient with ADL’s (activities of daily living)
Assist x2: Two people are needed to assist patient with ADL’s

You can also put an example of “Assist x1 transfer to bathroom” if the patient only needs help ambulating to the
bathroom and is independent with other activities like feeding.

NEURO
A&O: Alert and Oriented. This looks at the patient’s level of awareness of reality at that moment by assessing their
knowledge of person, place, time, and situation.

A&Ox1: Patient is alert and oriented to person. “What is your name?”

A&Ox2: Patient is alert and oriented to place. “Do you know where we are?”
A&Ox3: Patient is alert and oriented to time. “Do you know what day it is?”
A&Ox4: Patient is alert and oriented to situation. “Do you know why you are in the hospital?”

TELE
What is their heart rhythm?
Examples: Normal Sinus Rhythm, Sinus Tachycardia, Sinus Bradycardia, Atrial Fibrillation, Atrial Flutter and more!

LINES
Examples:
Peripheral IV: Most common. IV line used to administer fluids and medications through a peripheral vein (ex: basilic
vein/cephalic vein in the arm).
PICC: Peripherally Inserted Central Catheter is a longer term use catheter.
Central Venous Lines: placed in a large vein in neck (jugular vein), chest (subclavian) or groin (femoral vein). Used to
administer meds, fluids, blood and measure central venous pressure.
PAL: Peripheral Arterial Line is used for an acute measure of blood pressure or blood monitoring.
Make sure to always make sure you have the RIGHT: med, patient, dosage, route, time, and documentation.
 FOLEY
This is a type of indwelling urinary catheter that drains urine and should be monitored since there is a high risk of
infection with this type.
There are other also external catheters (PureWick is a external female urinary catheter, condom catheters are used for
males).

SKIN
Skin color: within normal limits (WNL), pallor, bluish discoloration, redness, yellow. Look for color differences between
comparable body parts (ex: right and left leg).
Temperature: dry, feverish, clammy, cool.
Edema: Grade pitting edema by:
+0: 0 mm or no pitting edema present
+1: 2 mm
+2: 4 mm
+3: 6 mm
+4: 8 mm
Turgor: if poor skin turgor, this could be a sign of dehydration. Pinch skin near clavicle so skin lifts up, then let go. If skin
goes back to normal placement, then that is normal.
Skin Integrity: wounds, cracks, openings, bruising, or scratches.

IV SITES
Check for any signs of complications. Common complications include:
Phlebitis: pain, increased skin temp and reddened line along vein.
Extravasation: pain, stinging, burning, redness at site.
Infiltration: edema, pallor, decreased skin temp, pain.

MEDS
Make sure to always make sure you have the RIGHT: med, patient, dosage, route, time, and documentation.

VITALS
Temperature: 98.6 F/ 37 C is normal. Fever is anything above 100.4 F/ 38 C.
Pulse: varies based on various factors. General guideline is Adult HR: 60-100, Child: 80-120, FHR: 110-160.
BP: varies based on various factors. General guideline is ~120/80 is normal.
Elevated: 120-129/ <80
Hypertension Stage 1: 130-139/80-89
Hypertension Stage 2: 140 or higher/ 90 or higher
Respirations: How many times their chest rises and falls within a minute. Adult normal: 12-20.
Oxygen Saturation: measure of how hemoglobin is bound to oxygen. Normal oxygen saturation: 95-100%.
Pain Level: varies by patient. Use O-L-D-C-A-A-R-T-S
O: Onset
L: Location
D: Duration
C: Characteristics (sharp, dull)
A: Aggravating Factors (what makes it worse)
A: Alleviating Factors (what makes it better)
R: Radiates
T: Treatment (what was already used to treat it)
S: Severity (0-10 pain scale)
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