Head to Toe Assessment Checklist NUR 245

Vital Signs Respiratory (assess anterior/posterior; R/L)

Temp________ oral/rectal/tympanic Clear R/L A/P
Pulse________regularity_______ Strength______ Diminished R/L A/P
Resp________regularity_______ Depth________ Absent R/L A/P
B/P_________Mode_________ Location_______ Crackles R/L A/P I/E
O2 Sat_______% RA_____ O2______L Rhonchi R/L A/P I/E
Wheezes R/L A/P I/E Audible
Pain Stridor__________ Moaning___________
P (pattern/precipitating factors)_______________ Cough_______________________________
Q (sharp/dull/stabbing/etc)___________________ Sputum (color/quantity/consistency)_________
R (region/radiating)________________________ ______________________________________
S (severity: on a scale of 0-10)_______________ Cardiovascular (apical pulse with stethoscope)
T (consistent/intermittent)___________________ Rate_____________ Rhythm______________
U (affecting ADLs)________________________ Clarity of sounds_________________________

Neurological Can you please tell me: Radial Pulses (strength/regularity)

1. Your name?__________________ Right___________ Left___________
2. Where you are?_______________ Capillary refill (1-3 sec; >3 sec=sluggish)
3. What year this is?_____________ Right fingers_____ Left fingers_____
4. Why are you here?____________ Hand strength (push/pulls/grip strength)
Right___________ Left___________
Lethargic ( ) Non-verbal ( )
Pedal Pulses (strength/regularity)
Pupil Check (pupils, equal, round, react to light, Right___________ Left___________
Accommodation) _______________________ Capillary refill (1-3 sec; >3 sec=sluggish)
Sluggish ( )______ Brisk ( ) ________ Right toes_______ Left toes________
Accommodation Yes ( ) No ( ) Foot strength (push/pulls)
Right___________ Left____________
Integumentary
Temp. (use back of hand) Edema (assess dependent areas: feet/hands/sacrum)
Hot ( ) Warm( ) Cold( ) R/L Hands Y/N Pitting Y/N _______sec
Color (check on inside of lip or conjunctiva) SacrumY/N Pitting Y/N _______sec
Lip ( ) Conjunctiva ( ) R/L Feet Y/N Pitting Y/N _______sec
Pink ( ) Pale ( ) Jaundice ( ) Cyanotic ( )
Turgor (1-3 sec return) Elimination
_____seconds (>3 sec = sluggish) Urinary: Continent______ Incontinent_____
Moisture: Dry ( ) Moist ( ) Diaphoretic ( ) Symptoms (burning/frequency…)____________
Catheter:______ Color________________
Skin Breakdown Assessment: Other:__________________________________
see Braden Scale on back
Bowel: Continent_____ Incontinent______
Fall Risk Assessment: Last BM__________________________
see Fall Assessment tool on back Flatus: yes_________ no_________
Bowel Sounds: (assess all 4 quadrants; do not
touch abdomen before auscultation as this will alter
normal sounds.)
RLQ Active ( ) Absent ( ) Hyperactive ( ) Hypo ( )
RUQ Active ( ) Absent ( ) Hyperactive ( ) Hypo
()
LUQ Active ( ) Absent ( ) Hyperactive ( ) Hypo ( )
LLQ Active ( ) Absent ( ) Hyperactive ( ) Hypo
()

Closure: Let pt know you are finished & when you will be back. Bedrails up? ___Bed in low position? __ Call light? ___
 Fall Assessment Tool

If no box is checked, score for category is 0 Points

Age
□60-69 years (1 point) □70-79 years (2 points) □≥ 80 years (3 points)
Fall History: □One fall within 6 months before admission (5 points)
Elimination
□Incontinence (2 pts) □Urgency or frequency (2 points)
□Urgency/frequency & incontinence (4 pts)
Medications: Includes PCA/opiates, Anticonvulsants, Antihypertensives, Diuretics, Hypnotics, Laxatives, Sedatives, & Psychotropics
□On one high fall-risk drug (3 points)
□On two or more high fall-risk drugs (5 points)
□Sedated procedure within past 24 hours (7 points)
Patient care equipment: any equipment that tethers patient (e.g., IV Infusion, Chest tube, Indwelling catheters, SCDs)
□One present (1 pt) □Two present (2 pts) □Three or more present (3 points)
Mobility (choose all that apply and add points together)
□Requires assistance or supervision for mobility, transfer, or ambulation (2 pts)
□Unsteady gait (2 points)
□Visual or auditory impairment affecting mobility (2 points)
Cognition (choose all that apply and add points together)
□Altered awareness of immediate physical environment (1 point)
□Impulsive (2 points)
□Lack of understanding of one’s physical and cognitive limitations (4 points)
Total: Moderate risk = 6-13 points High risk= > 13 points

Braden Scale for Predicting Pressure Sore Risk pt. score

Sensory 1. Completely Limited.. 2. Very Limited. 3. Slightly Limited. 4. No Impairment.
Perception Unresponsive (does not moan, Responds only to painful Responds to verbal commands, Responds to verbal commands.
flinch, or grasp) to painful stimuli. Cannot communicate but cannot always communicate Has no sensory deficit which
Ability to stimuli due to diminished level discomfort except by discomfort or the need to be would limit ability to feel or
respond of consciousness or sedation moaning or restlessness. turned. voice pain or discomfort.
meaningfully OR OR… Has a sensory OR…
to pressure- Limited ability to feel pain over impairment which limits the Has some sensory impairment
related most of body ability to feel pain or which limits ability to feel pain
discomfort. discomfort over ½ of body. or discomfort in 1-2 extremities.

Moisture 1. Consistently Moist 2. Very Moist 3. Occasionally Moist 4. Rarely Moist

Degree to Skin is kept moist almost Skin is often, but not always, Skin is occasionally moist Skin is usually dry, linen only
which skin is constantly by perspiration, urine, moist. Linen must be changed requiring an extra linen change requires changing at routine
exposed to etc. Dampness is detected every at least once a shift. approximately once a day. intervals.
moisture. time patient is moved or turned.

Activity 1. Bedfast 2. Chairfast: Ability to walk 3. Walks occasionally. Walks 4. Walks Frequently.
Confined to bed. severely limited or non- occasionally during day, but for Walks outside room at least
Degree of existent. Cannot bear own very short distances, with or twice a day and inside room at
physical weight and/or must be without assistance. Spends least once every 2 hours during
activity assisted into chair or majority of each shift in bed or waking hours.
wheelchair. chair.

Mobility 1. Completely immobile. Does 2. Very limited. 3. Slightly limited. 4. No limitation.

not make even slight changes in Makes occasional slight Makes frequent though slight Makes major and frequent
Ability to body or extremity position changes in body or extremity changes in body or extremity changes in position without
change and without assistance. position but unable to make position independently. assistance.
control body frequent or significant
position changes independently.

Nutrition 1. Very poor. 2. Probably Inadequate 3. Adequate 4. Excellent

Never eats a complete meal. Rarely eats a complete meal Eats over half of most meals. Eats most of every meal. Never
Usual food Rarely eats more than 1/3 of any & generally eats only about ½ Eats a total of 4 servings of refuses a meal. Usually eats a
intake pattern food offered. Eats 2 servings or of any food offered. Protein protein (meat, dairy) per day. total of 4 or more servings of
less of protein (meat or dairy intake includes only 3 Occasionally will refuse a meal, meat and dairy products.
products) per day. Takes fluids servings of meat or dairy but will usually take a Occasionally eats between
poorly. Does not take a liquid products per day. supplement when offered. meals. Does not require
dietary supplement Occasionally will take a OR supplementation.
OR dietary supplement.. OR Is on a tube feeding or TPN
Is NPO &/or maintained on clear Receives less than optimum regimen which probably meets
liquids or IVs for more than 5 amt of liquid diet or tube most of nutritional needs.
 days. feeding

Friction & 1. Problem: Requires moderate to 2. Potential problem. Moves feebly or requires 3. No apparent problem.: Moves in bed
Shear maximum assistance in moving. Complete minimum assistance. During a move skin and in chair independently and has
lifting without sliding against sheets is probably slides to some extent against sheets. sufficient muscle strength to lift up
impossible. Frequently slides down in bed Maintains relatively good position in chair or completely during move. Maintains
or chair, requiring frequent repositioning bed most of the time but occasionally slides good position in bed or chair Total
with maximum assistance. Spasticity, down.
contractures or agitation leads to almost
constant friction.

Score: 15-18 At risk; 13-14 Moderate risk; 10-12 High risk; ≤ 9 VERY high risk