Head Toe Assessment PDF Details

Are you looking for a way to more effectively assess your patients? If so, you may want to consider using the Head Toe Assessment Form. This form can help you to better identify any problems that your patients may be experiencing. By using this form, you can ensure that you are providing the best possible care for your patients.

If you'd like to first learn how much time you will need to prepare the head toe assessment and what number of pages it's got, here is some detailed information that might be useful.

QuestionAnswer
Form NameHead Toe Assessment
Form Length2 pages
Fillable?Yes
Fillable fields82
Avg. time to fill out16 min 58 sec
Other nameshead to toe assessment checklist, head to toe assessment, head to toe nursing assessment form, assessment head toe

Form Preview Example

Head to Toe Assessment

Student Name:

 

 

 

Student Signature:

 

 

 

Evaluator Signature: 1st attempt

 

 

Date:

Satisfactory*

Unsatisfactory^

 

 

 

 

 

 

 

 

Evaluator Signature: 2nd attempt

 

Date:

Satisfactory*

Unsatisfactory^

 

 

 

 

 

 

Satisfactory*

Unsatisfactory^

Evaluator Signature: 3rd attempt

 

 

Date:

 

 

order

 

 

 

 

 

** Critical Behaviors that need to be stated or done in

to pass theskill.

 

 

 

 

 

 

 

 

 

 

 

 

PERFORMANCE BEHAVIORS

 

S* U^ COMMENTS

Planning

1.Gather equipment needed for assessment

a.Stethoscope

b.Appropriate sized blood pressure cuff

c.Pulse Oximeter

d.Penlight

e.Thermometer

f.Gloves

2.Upon entering the patient’s room:

a.**Perform hand hygiene

b.Identify self

c.**Identify patient using 2 forms of ID (name and date ofbirth)

d.**Verify patient allergies

e.Assure privacy

f.**Explain what is about to occur

g.Allow for patient questions

h.Raise bed to comfortable working height

i.Don gloves

Assessment

3.**Assess level of consciousness and orientation to person, time and place.

4.Perform assessments for pain, pulse oximetry, blood pressure, pulse, respiratory rate, and temperature.

5.Assess head and PERRLA (Pupils Equal, Round, React to Light, and Accommodation)

a.Observe for any gross abnormalities of the head and face.

6.**Throughout assessment observe and note condition of hair, skin and nails.

7.** Assess and compare bilateral upper extremities for:

a.Hand grasps for equality and strength

b.Temperature and color

c.Radial pulses

d.Capillary refill

e.Sensation

8.**Assess apical pulse.

a.Auscultate heart sounds at left mid-clavicular line fifth intercostal space. Point of maximal impulse (PMI).

b.Listen for one full minute, noting rate and regularity.

9.**Assess lungs.

a.Listen and observe rise and fall of chest and count respirations.

b.Auscultate breath sounds.

1.Assess anterior chest in 4 sites and 2 lateral sites.

2.Assess posterior chest in 4 sites and 2 lateralsites.

**Critical Behaviors that need to be stated or done in order to pass the skill.

Skill Sheet Head to Toe Assessment SP2022

PERFORMANCE BEHAVIORS

*S *U COMMENTS

10.**Assess abdomen (Inspection, Auscultation, Palpation)

a.Auscultate for bowel sounds in all four quadrants

b.Palpate abdomen for firmness, tenderness, and lower abdomen for bladderdistention.

11.**Assess and compare bilateral lower extremities for

a.Movement and strength

b.Temperature and color

c.Dorsalis pedis and posterior tibial pulses

d.Capillary refill

e.Sensation

12.Assess posterior lung sounds (if not done previously) and skin

13.**Check equipment related to the patient

a.IV? Solution, rate, site.

b.O2? Setting/type

c.Drains (including urinary catheter).

14.Survey the environment for safety concerns.

a.**Reposition patient for comfort and safety

15.Prior to leaving room

a.**Lower bed

b.**Raise appropriate bed rails

c.**Place call light and patient belongings within reach

d.**Perform hand hygiene

e.Gather and remove equipment

Evaluation

16. **Document assessment per facility policy

*S = Satisfactory, ^U = Unsatisfactory

**Critical Behaviors that need to be stated or done in order to pass the skill.

17. Write a sample nursing note:

Skill Sheet Head to Toe Assessment SP2022

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Create the next parts to complete the document:

example of gaps in head toe assessment

Make sure you type in the necessary data in the Assesslungs, Assessapicalpulse, and impulsePMI field.

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Focus on the most essential details of the PERFORMANCEBEHAVIORS, Checkequipmentrelatedtothepatient, IVSolutionratesite, Priortoleavingroom, and COMMENTS field.

Completing head toe assessment stage 3

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stage 4 to filling out head toe assessment

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