Assessment Head Toe 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 Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesassessment head toe, toe assessment, head to toe assessment form pdf, head to toe nursing assessment form

Form Preview Example

An Easy Guide to Head to Toe Assessment

©Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Neurological Assessment

Oriented to:

Person Place

Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Communication/ Speech: WNL

Non-verbal

Dysarthria

Aphasia: Expressive Receptive

Global

 

Pupils: PERRLA OR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Equal: Yes No R larger L larger

Round:

Yes No R abnormal shape L abnormal shape

 

 

Reactive to Light: Yes

N

 

Reaction: Brisk Sluggish

R no reaction L no reaction

 

 

Accommodation: R L (hold finger 4” above nose, bring closer to face, do both eyes maintain focus?)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Glasgow Coma Scale (Score range 0 to 15, Coma =< 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

Eye opening to:

 

 

Spontaneous = 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verbal command = 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pain = 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No response = 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Verbal response to:

 

Oriented, converses = 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disoriented, converses = 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Uses inappropriate words = 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Incomprehensible sounds = 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No response = 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Motor response to:

 

Verbal command = 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Localized pain = 5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flexes and withdraws = 4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Flexes abnormally (decorticate) = 3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Extends abnormally (decerebrate) = 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No response = 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Location

 

 

Muscle Tone

 

Muscle

 

 

 

 

 

Sensation

 

 

 

Tremor

 

 

 

 

 

 

 

 

 

 

 

Strength

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Head/ Neck

WNL

Flaccid

Spastic

 

 

 

 

WNL

To pain

No response to

 

No

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pain

 

 

 

 

 

 

 

 

 

 

 

R hand

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L hand

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RUE

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LUE

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RLE

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LLE

WNL

Flaccid

Spastic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Muscle Strength: 5 = WNL

4 = 75% normal 3 = 50% normal

2 = 25% normal

1 = 10% normal

0 = complete paralysis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory Assessment

 

 

 

 

 

 

 

Pulse ox: WNL (95-100%)

WNL for this patient at _____

 

 

 

 

 

 

 

 

 

 

Cough: None

Non-productive, dry

Productive Productive sounding, no sputum

 

 

 

 

Sputum: None

Consistency: Thick

Thin

Foamy

Color: White

Other, __________________

Oxygen: N/A Room air

____ liters/ nasal cannula

____ % per face mask

Mechanical ventilator

 

 

Respiratory rate:

WNL

Tachypnea/ hyperventilation (too fast)

Bradypneic/ hypoventilation (too slow/ shallow)

Respiratory effort: Relaxed and regular

Pursed lip breathing

Painful respiration

Labored

 

 

 

Dyspnea at rest Dyspnea with minimal effort, talking, eating, repositioning in bed, etc.

 

 

 

 

 

Dyspnea with moderate exertion, dressing, walking =< 20 feet, etc.

Dyspnea when walking ____ feet or with exercise

Recovery time following dyspneic episode: _____ minutes

 

 

 

 

 

 

 

 

 

 

 

 

 

Respiratory rhythm:

WNL

Regular, tachypneic

Regular, bradypneic

Regular with periods of apnea

Regular pattern of increasing rate and depth, followed by decreasing rate and depth, followed by apnea (Cheyne-Stokes) Regular, abnormal, rapid and deep respiration (central neurogenic hyperventilation)

Regular, abnormal, prolonged inspiration with a pause or sigh with periods of apnea (apneustic) Irregularly irregular pattern/ depth (ataxic) Irregular with periods of apnea (cluster breathing)

Breath sounds (auscultate anterior & posterior, R & L upper, mid, lower chest):

Clear (vesicular) throughout

Decreased (atelectasis?)

Crackles: Fine (sounds like hair rubbing) Coarse/ moist

Gurgles/ rhonci (low pitched, moaning, snoring sounds)

Wheezes: Inspiratory Expiratory

Friction rub (sounds like leather rubbing against leather)

Absent (pneumothorax?)

Upper chest:

Right ________________

Left ________________

Mid chest:

Right ________________

Left ________________

Lower chest:

Right ________________

Left ________________

An Easy Guide to Head to Toe Assessment

©Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Cardiovascular Assessment

Skin: Warm/ dry

Cool Clammy/ diaphoretic

Skin turgor: WNL Tenting

Weight: ________ kg/ lb

Capillary refill: WNL Delayed > 2 seconds

 

 

 

 

 

 

Apical pulse rhythm:

Regular Regularly irregular

Irregularly irregular

 

Apical pulse rate:

 

 

 

 

Heart sounds:

 

 

 

WNL (60-100)

 

 

 

 

Normal S1S2

S3 (gallop)

 

Bradycardia

 

 

 

 

Valve click [artificial heart valve]

 

Tachycardia

 

 

 

 

Murmur:

 

 

 

(Extremely low or high HRs

 

 

 

 

Holosystolic

 

decrease C.O., blood and O2

 

 

 

 

Midsystolic

 

to the vital organs).

 

 

 

 

 

Diastolic

 

 

 

Apical/ radial deficit: No Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Peripheral Pulses

 

 

 

 

Edema

 

 

 

 

R radial

Yes

Doppler

No

R hand/ arm

No

Non-pitting

Pitting ___+

 

 

 

R femoral

Yes

Doppler

No

R knee to thigh

No

Non-pitting

Pitting ___+

 

 

 

R pedal

Yes

Doppler

No

R ankle to knee

No

Non-pitting

Pitting ___+

 

 

 

R post tib

Yes

Doppler

No

R foot/ ankle

No

Non-pitting

Pitting ___+

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L radial

Yes

Doppler

No

L hand/ arm

No

Non-pitting

Pitting ___+

 

 

 

L femoral

Yes

Doppler

No

L knee to thigh

No

Non-pitting

Pitting ___+

 

 

 

L pedal

Yes

Doppler

No

L ankle to knee

No

Non-pitting

Pitting ___+

 

 

 

L post tib

Yes

Doppler

No

L foot/ ankle

No

Non-pitting

Pitting ___+

 

 

 

 

 

 

 

Sacrum

No

Non-pitting

Pitting ___+

 

 

ECG assessment if applicable, see below

Genitourinary Assessment

Genitalia: WNL Abnormalities, describe: ______________________________________________________________

Assessment of urination: WNL Burning

Frequency Urgency

Bladder distention Pelvic pain/ discomfort

Lower back/ flank pain/ discomfort

Continent: Yes Stress incontince with coughing, etc. Rarely incontinent Regularly incontinent

Urine amount: WNL (over 30 mls/ hr, output approximates intake)

Less than 30 mls/ hr (dehydration? Post-op volume depletion? SIADH?)

Output greatly exceeds intake (Post-op diuresis? Diabetes insipidus?)

Urine color: Yellow, WNL

Amber Orange

Dark amber

Pink Red tinged Grossly bloody

Urine characteristics:

Clear, WNL

Cloudy

Sediment Abnormal odor

Urostomy: N/A

Urostomy/ ileal conduit Continence maintaining nipple valve ostomy

Stoma status:

Pink, viable

Red

Deep red

Dusky Dark Retracted below skin S/S of infection

Urinary stents:

N/A

R ureter

L ureter

 

 

 

Urinary catheter:

N/A

Foley, short term

Foley, long term at

home

Suprapubic catheter

Insertion site: WNL

S/S of infection

 

An Easy Guide to Head to Toe Assessment

©Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Gastrointestinal Assessment

Oral mucosa: Intact

Moist

Dry

Pink Pale

Tongue: WNL

Pink White patches

Abdomen: WNL

Distended Taut

Ascites Abdominal incision

Abdominal girth (PRN): ____ cm

Abdominal pain, see pain assessment

 

 

 

 

Bowel movements: WNL Constipation

Diarrhea Bowel program required Other, __________________

(if diarrhea, assess risk for C. diff or VRE)

 

 

 

 

Last bowel movement: Today

Yesterday

Other, ____________________________________________________

Continent: Yes Rarely incontinent

Regularly incontinent

 

 

Nausea/ vomiting: No Yes, describe: ________________________________________________________________

Nutritional intake: Adequate Inadequate, address in care planning Bowel sounds (all four quadrants):

Active, WNL Hyperactive

Hypoactive Absent (listen for 5 full minutes)

Tubes: None

Salem sump Nasoduodenal feeding tube

PEG tube

Jejunostomy (J) tube pH aspirate: ___

Insertion site: WNL

Pressure areas Redness

Purulent drainage

Tenderness Warmth

Tube feeding: Type: ________________

Amount: ____ mls over ____ hours via

Gravity

Pump

Intermittent

Continuous

(keep head of bed elevated to prevent aspiration, check placement pH should be 0 to 4)

Stoma: N/A

Colostomy

Ileostomy

(Notify the surgeon of all abnormalities observed for new colostomies)

Stoma status: Pink, viable

Red

Deep red Dusky

Dark Retracted below skin S/S of infection

PEG tube = percutaneous endoscopic gastrostomy tube

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Skin Integrity Assessment

 

 

Skin color: WNL

Pale

Jaundice

Dusky

Cyanotic

 

 

Skin is: Intact

No, see below No, describe: ___________

 

Braden Scale Score: _______

Signs/ symptoms of inflammation/ infection: Redness

Tenderness/ pain

Warmth

Swelling

Location(s):

 

 

 

 

 

 

 

 

 

Contusion(s)/ Ecchymosis: N/A Size:

Length _____ cm Width _____ cm

Depth _____ cm

Location(s): ____________________ Client’s explanation of bruising: _________________________________________

Wounds

 

Location

Type

Size

Tunneling

Undermining

Surrounding

Drainage

 

 

 

 

 

 

 

Tissue

 

 

 

 

 

Abrasion

Length ____

None

None

WNL

Color/

 

 

 

 

Avulsion

cm

 

 

 

Characteristics:

 

 

 

Burn

 

Present at

Present,

Redness

Serous

 

 

 

Laceration

Width ____ cm

_____ o’clock,

surrounding

Tenderness

Serosanguinous

 

 

 

Puncture

Depth ____ cm

depth ______

tissue is:

Pain

Bloody

 

 

 

Pressure ulcer,

cm

Dusky

Warmth

Yellow

 

 

 

Stage _________

 

 

Soft

Streaking

Tan

 

 

 

 

Stasis ulcer

 

 

Boggy

Excoriation

Brown

 

 

 

Surgical incision,

Incision length

Present at

Fluid-full

Bruising

Green

 

 

 

 

closed, edges are

___________

_____ o’clock,

Other,

Discolored

Purulent?

 

 

 

approximated

cm

depth ______

describe:

Dusky

 

 

 

Surgical,

 

cm

 

 

No

Yes

 

 

 

open areas

_______ # of

 

 

Wound edges

 

 

 

 

 

total wound

staples/

 

 

WNL

Odor?

 

 

 

 

dehisence

sutures

 

 

Hyperkeratotic

No

Yes

 

 

 

______________

(circle one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is client on a pressure reduction or relief surface: No Yes, type: __________________________________________

*Undermining is due to liquefication of necrotic tissue or mechanical forces that sheared and separated underlying tissues.

An Easy Guide to Head to Toe Assessment

© Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Pain Assessment

Location of pain: __________________________________ Pain is: Acute Chronic Constant

Intermittent

Pain is affecting: N/A Sleep Activity Exercises Relationships Emotions Concentration

Appetite Other: __________________________________________________________________________________

Description of pain: Sharp

Stabbing

 

Throbbing

Shooting Burning Electric-shock like

Pain rating on a scale of 0 to 10: ______

Acceptable level of pain for this client: ________

 

 

Highest pain level today: _______

 

Best pain level today: _______

Best pain ever gets: _______

What makes the pain worse? Activity

Exercises Other: ______________________________________________

What makes the pain decrease? Rest/ sleep

Medication

Heat

Cold

Family presence

Music

Reading

Distraction

Meditation

Guided imagery Relaxation techniques

Other: _______________

Opiod medication(s): __________________________________________________ Route: _____

Last dose: ____________

Breakthrough medication(s): ___________________________________________ Route: _____

Last dose: ____________

NSAIDS/ Adjuvants: __________________________________________________ Route: _____

Last dose: ____________

PCA: N/A

Morphine

Dilaudid

 

Fentanyl

via

IV

Epidural, dressing: D&I

_____________

Continuous dose: ________ / hr Demand dose: _____ every _____ minutes

Max doses per hour: _____

(Assess pain every 2 to 4 hours, evaluate the # of attempts vs the # of demand doses received to determine if dose is sufficient)

Does the client have concerns about overusing medications/ addiction? No

Yes, _____________________________

 

 

 

 

IV Assessment

 

Type of line:

Peripheral, site __________ Triple lumen CVL PICC

Tunneled CVL Implanted port

 

(check CXR for catheter tip placement before using all new central venous and PICC lines)

Insertion site:

WNL Redness Tenderness/ pain Warmth Swelling Drainage

(IV needs to be DC’d if s/s of infection, thrombophlebitis or pain is present. Change PIV, notify MD of PIV and CVL concerns)

IV fluids: N/A, heplock

IV fluids: _________________ @ _____ mls/ hr

Continuous over ___ hrs

IV pump

Dial-a-flo

 

Gravity

 

 

TPN/ PPN: N/A TPN

PPN @ _____ mls/ hr

Continuous over ____ hrs per ________ pump

Blood sugars:

q 6 hrs

q 8 hrs other: _______

Blood sugars ranges: WNL High with coverage needed

PCA: N/A

Morphine

Dilaudid Fentanyl

via IV Epidural, dressing: D&I _____________

Continuous dose: ________ / hr Demand dose: _____ every _____ minutes

Max doses per hour: _____

(Assess pain every 2 to 4 hours, evaluate the # of attempts vs the # of demand doses received to determine if dose is sufficient)

 

 

Cast/ Extremity Assessment

Hot spots over cast?

No

Yes, describe:

Cast intact:

Yes

No, describe:

Drainage:

None

Yes, describe:

Extremity check

 

 

Color:

WNL

Pale

Temperature:

Warm

Cool

Sensation:

WNL

Loss of sensation

Pain increasing?

No

Yes, describe:

Swelling increasing?

No

Yes, describe:

TYPES OF APHASIA:

Dysarthria – patient has problems with speech due to muscular control.

Expressive aphasia (Broca’s) – patient understands, can respond w/ great difficulty in short abbreviated, phrases. Aware and

frustrated. Often frontal lobe damage.

Receptive aphasia (Wernicke’s) – patient cannot understand spoken and sometimes written words, speaks fluently, long sentences that do not make sense. Patient may not be aware of deficits. Often secondary to L temporal lobe damage.

Global or mixed aphasia – patient has difficulty in understanding and speaking/ communicating. Often secondary to extensive damage of the language areas of the brain.

ASSESSMENT FOLLOW UP:

Notify the physician of all abnormal findings!!

Use the nursing process to:

oAnalyze subjective and objective findings.

oMake a nursing diagnosis.

oPlan and implement appropriate interventions.

oEvaluate the effectiveness of the plan and revise as needed.

An Easy Guide to Head to Toe Assessment

©Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Putting it All Together

As you walk into the room assess:

*Awake/ alert, asleep?

*Skin color

*Respiratory effort

At the head assess:

*Skin color, temp, moisture and integrity

*Incisions and dressings

*Oral mucosa/ tongue

*Skin tenting on forehead

*Tremors

*Pupils

*Jugular/ subclavian CVL

*NG/ Nasoduodenal tube

At the upper extremities assess:

*Skin color, temp, moisture and integrity

*Incisions and dressings

*Capillary refill

*Radial pulses

*Skin tenting on forearm

*Edema

*Periph IV/ PICC insertion sites

*Tremors

*Hand grasps

*Muscle tone and strength

*Casts

At the genitalia/ buttocks:

*Skin color, temp, moisture and integrity

*Incisions and dressings

*Femoral pulses

*Sacral edema

As you converse with the patient assess:

*Orientation to person, place, time

*Communication/ speech

*Respiratory effort and rhythm

*On/ off O2

*Glasgow coma score

*Pain

At the chest/ back assess:

*Skin color, temp, moisture and integrity

*Incisions and dressings

*Breath sounds

*Respiratory rate, depth, rhythm and effort

*Oxygen settings

*Apical pulse

*Apical/ radial deficit

*Heart sounds

At the abdomen assess:

* Skin color, temp, moisture and integrity * Incisions and dressings

* Nutritional intake * Nausea/ vomiting * Bowel movements * Distention/ ascites * Bowel sounds

* PEG/ J tube site * Tube feedings * Stomas

* Continence

* Abdominal/ flank pain

* Bladder distention, s/s of UTI

* Urine output, color, characteristics

* Urinary catheter

 

 

At the lower extremities assess:

 

 

 

 

 

 

 

* Skin color, temp, moisture and integrity

* Incisions and dressings

 

 

 

 

* Pedal and posterior tibial pulses

 

* Capillary refill

 

 

 

 

 

* Edema

 

 

* Tremors

 

 

 

 

 

* Muscle tone and strength

 

 

* Casts

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Notify the Physician of abnormal findings of concern

* Implement the nursing process

* Analyze the data

 

 

* Identify the appropriate nursing diagnoses.

* Develop and implement a plan

* Evaluate the outcomes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

An Easy Guide to Head to Toe Assessment

©Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com

Cardiac Rhythm Assessment by ECG

Sinus rhythm:

Normal sinus rhythm (NSR) [P wave before every QRS, P-R interval < 0.20, rate is between 60 to 100]

Sinus tachycardia [rate => 101]

Sinus bradycardia [rate =< 59]

Sinus arrhythmia [P wave before every QRS, but rate varies with respiration]

Atrial dysrhythmias:

Atrial fib* [atria of heart is fibrillating, ECG shows wavy line, conduct ion thru A-V node to ventricles is erratic]

Atrial flutter with __:1 conduction block [atrial rate approx 300, ventricular (heart) rate 150 = 2:1, HR 75 = 4:1]

Atrial fib/ flutter [atria mixture of flutter and fibrillation]

Paroxysmal supraventricular tachycardia (PSVT) [sudden onset, very fast rates, narrow QRS, P wave absent or behind QRST]

A-V Heart Blocks:

First degree heart block [delayed conduction thru AV node, P-R interval > 0.20]

Second degree A-V block, Mobitz I**[P-R interval lengthens until a QRS is absent, cyclic pattern with every X beat dropped]

Second degree A-V block, Mobitz II*** [P-R interval is stable, no QRS after some P waves due to intermittent AV block]

Third degree A-V block** [no relationship between P waves and QRS complexes due to complete block at AV node]

Paced Rhythms:

 

 

 

Atrial-ventricular (AV) sequential pacing [spike before the P wave and spike before the QRS] 1:1?

Yes

No

Ventricular pacing [pacing spike before the QRS only]

1:1? Yes No

 

 

Demand pacing [heart rate is higher, pacemaker fires only if there is a delay in spontaneous activity]?

Yes

No

Automatic internal defibrillator (IAD)? No Yes

Has client felt it fire? No Yes, when _________________

Ectopic Beats:

Ventricular premature beats (VPB, PVC) [an early, wide QRS, extra beat originating in the ventricle]

Bigeminy [every other beat is a VPB] Trigeminy [every 3rd beat is a VPB] Quadrigeminy [every 4th beat is a VPB]

Premature atrial beats (PAB, PAC) [an early, narrow QRS, extra beat originating in the atria, P wave shape may be different]

Premature junctional beats (PJB) [an early, narrow QRS, extra beat originating above the A-V node, no P wave]

Lethal dysrhythmias:

Ventricular escape rhythm (also called idioventricular) [wide QRS complexes, HR @ ventricular intrinsic rate, 30- 40]

Ventricular tachycardia [wide QRS, tachycardic rates, minimal cardiac output due to ineffective pumping, cannot sustain life]

Ventricular fibrillation [erratic line, ventricles are quivering, no pumping action, cardiac output is 0]

*A fib with rapid response (HR > 100) increases myocardial oxygen needs and risk of LV failure is high, also high risk for PE. **Previously called Wenckebach. ***Mobitz II second degree and third degree block can result in life threatening bradycardia.

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