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Basic Head-to-Toe Assessment


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Basic Head-to-Toe Assessment

  1. 1. Basic Head-to-Toe Assessment History of present illness – Brief synopsis of illness from admission to day of care; include treatment and patient responses/condition. Vital signs: -Temp, pulse, RR, BP, O2 sat, Ht/Wt (can also be listed in appropriate system) Neurological: -Appropriateness of response, speech, affect -Visual acuity -Pupils (PERRLA) -Gait, handgrips, moves all extremities equally -Neuro deficits (facial drooping, etc) Pain: location, rating (0-10), FACES pain rating scale Cardiovascular: -Apical pulse (auscultate for S1 and S2, rate and rhythm in all areas) -Telemetry (rhythm) -Peripheral pulses bilaterally (strength and equality) -Calf tenderness -Edema (location/pitting or non-pitting) -Capillary refill -IV site, fluid (type, rate), condition Respiratory: -Observe respiratory rate/rhythm/depth -Auscultate anterior & posterior lung sounds -Cough: productive/non-productive Supplemental oxygen, O2 saturation Gastrointestinal: -Mouth: condition of teeth, moisture and color of mucous membranes, dentures, swallowing -Abdomen: inspect shape, auscultate bowel sounds, palpate and assess for distension, tenderness, masses -Last BM (date, quantity, color, consistency) -Diet/NPO -NG tube/feeding tube Genitourinary: -Urine output, color, burning -Voids, Foley, incontinent, dialysis -Observe and palpate for distended bladder -Ask about penile or vaginal drainage, sexual concerns. -LMP (women of childbearing age) Musculoskeletal: -Range of motion, muscle strength Integument: -Skin color, turgor, temperature, moisture, lesions Psychosocial: -Cultural, social, spiritual supports and concerns Equipment: -Special equipment used for care (traction, SCD, TED, IS, etc) can also be listed in appropriate system