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Head To Toe Assessment

A head-to-toe assessment was conducted including vital signs, neurological status, inspection and palpation of the head, eyes, ears, nose, mouth, neck, chest, abdomen, back, extremities, skin, and pain assessment. The assessment checked things like orientation, breath sounds, bowel sounds, pulses, edema, sensation, range of motion, strength and documented findings in each body system or area. The purpose was to gather full patient assessment data.

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9K views2 pages

Head To Toe Assessment

A head-to-toe assessment was conducted including vital signs, neurological status, inspection and palpation of the head, eyes, ears, nose, mouth, neck, chest, abdomen, back, extremities, skin, and pain assessment. The assessment checked things like orientation, breath sounds, bowel sounds, pulses, edema, sensation, range of motion, strength and documented findings in each body system or area. The purpose was to gather full patient assessment data.

Uploaded by

Ben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Head-to-Toe Assessment

Assessment conducted by

Date:
Time:

LOC
Alert Drowsy Lethargic
StuporousComa
Orientation
Person
Place
Time
Situation
Vitals
Temp
R
BP
Pulse Ox
Head
Hair
PERLA
Nose
Ears
Mouth
o Midline tongue

o Other:

mm

o Moist
o Lesions
o Dentition
Neck
Carotid pulse
JVD + Trachea midline
Chest
Apical Pulse
Muffled Arrhythmia
Breath Sounds - Anterior
Posterior
Lateral
Chest Symmetry
Skin Turgor (clavicle)
Abdomen
Inspection
Ausculation
o LUQ (active / hyper
o RUQ (active / hyper
o LLQ (active / hyper
o RLQ (active / hyper
Palpation

/ absent)
/ absent)
/ absent)
/ absent)

Temp vs. trunk (warm / cool)


Grip equal and strong
Capillary refill <3 sec
Vein filling rapid

Lower Extremities
Hair present
Edema
Foot strength
Homain's (+ / -) Claudication (+ / -)
Temp vs. Trunk (warm / cool)
Nails Yellowed Thickened Ingrown
Pedal pulse R(palp / doppler) L(palp / doppler)
ROM
/
Strength
Upper R
Upper R
Upper L
Upper L
Lower R
Lower R
Lower L
Lower L
Sensation
General Assessment
Weight/Height
BM
Pain Assessment
Acute/Chronic Intensity (0-10)
Location
Duration
Characteristics
Precipitation
Frequency
Non-verbals
Relief factors
Sleep
Skin Assessment
Description:

Upper Extremities
Radial pulses equal, +2
Courtesy of http://nursing.arizela.com

Courtesy of http://nursing.arizela.com

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