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Head To Toe Assessment Guide

This document provides a cheat sheet for conducting a head-to-toe assessment. It outlines the key areas to examine including general survey, vital signs, skin, head, cardiac, respiratory, abdomen, gastrointestinal, genitourinary, and skin. For each area, it lists the specific things to inspect, auscultate, palpate, and note such as eyes, ears, mouth, heart sounds, lung sounds, bowel sounds, masses, edema and more to thoroughly assess the patient.

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Sara Sabra
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451 views

Head To Toe Assessment Guide

This document provides a cheat sheet for conducting a head-to-toe assessment. It outlines the key areas to examine including general survey, vital signs, skin, head, cardiac, respiratory, abdomen, gastrointestinal, genitourinary, and skin. For each area, it lists the specific things to inspect, auscultate, palpate, and note such as eyes, ears, mouth, heart sounds, lung sounds, bowel sounds, masses, edema and more to thoroughly assess the patient.

Uploaded by

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

Norma Gail Yearick, MSN, RN

General Survey:

 Observe and note gender & race, age, signs of distress, body type, hygiene & grooming, dress,
body odor, affect & mood, speech, and signs of physical and/or substance abuse.
 Mental status = alertness and orientation to person, place, time, and situation.
 Vital signs = temperature, pulse, respirations, blood pressure, & oxygen saturation.
 Skin = color, temperature, lesions, turgor.

Head:

 Eyes
o Sclera (color)
o Conjunctiva (color & moistness)
o Pupils (equally round, reactive to light, and accommodating)
o Vision (Snellen chart, glasses or contacts)
 Ears
o Appearance (discharge, wax)
o Hearing (whisper test, hearing aids, ability)
 Mouth
o Lips (cracks & lesions)
o Oral Mucosa (color, moistness, lesions)
o Teeth (dental caries, cracks, missing teeth, dentures)

Cardiac

 Pulse Points (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial)
 Heart Sounds
o Regular or irregular
o S1 = left fifth intercostal space (mitral valve)
o S2 = right second intercostal space (aortic
o S1 and S2 = one heartbeat
o Abnormal sounds (murmur, clicks, rubs)
 Capillary Refill
o Return to pink in < 3 seconds after pinching skin = good capillary refill.
 Edema (trace, +1, +2, +3, +4)
 Skin Color
 Skin Temperature
o Feel with back of hand; should be symmetrical)

Respiratory
 Inspection
 Chest shape; accessory muscle use; chest excursion
 Breathing Pattern
 Auscultation (26 auscultation points = 8 anterior, 4 lateral, and 10 posterior)
 Abnormal Sounds = rales (crackles), rhonci, wheezes, pleural friction rub

Abdomen

 Inspection (contour)
 Auscultation
o 4 quadrants; umbilicus is center of each quadrant
o Should hear bowel sound within 5 to 20 seconds
o If no bowel sound in 5 minutes = bowel sounds are absent = problem!
 Palpation
o Lightly palpate each of the 4 quadrants
o Feel for masses, pulsations, and complaints of pain

Gastrointestinal & Genitourinary

 Bowel habits & characteristics


 Voiding habits & characteristics

Skin

 Check pressure points


o Bony prominences
 Legs
o Shins for ulcers

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