Head to Toe Assessment

1. Head to Toe Assessment

2. Head • Eyes: check sclera, conjunctiva, accomodation, PERRLA • Mouth: pink, moist, without odor, teeth alignment, number of teeth, throat: redness, exudate, lesions

3. Neck • Alignment: flexibility • Vascular: palpate carotid pulsations, listen for Carotid bruit • Bruit: swishing sound heard with stethoscope at carotid artery. • Lymph nodes: palpate for swelling

4. Chest • Breathing: bilateral sounds, inspiration and expiration, rales, rhonchi, crackles • Heart Sounds:S1 and S2= lubb dubb. Note rate, regularity rhythm • Note AP should be 1:2 ratio

5. Abdomen • Palpate for tenderness, guarding, • Listen to Bowel Sounds in all 4 quadrants. RU, RL, LU, LL • Note quality of sounds, hypoactive, hyperactive, without sound

7. Appendicular Assessment • Arms: check for bilateral alignment, note grip strength, as well as ability to release grip • Note capillary refill in fingertips • Legs: Check for bilateral alignment, note reflexes(Babinski) as well as strength of flexion and extension(gas pedal), varicose veins

8. Skin Color • Note any changes in complexion: • Jaundice • Cyanosis • Darker skinned patients may appear pale instead of a bluish tint.

9. Mental Status • Orientation: • Name • Day of week • Date • Who is president • Situation: If other assessments are negative.

10. Mental Status-Level of Consciousness • Alert: aware of situation and surroundings • Decreased LOC: somewhat awake, easy to fall into sleep, may or may not be aware of situation or surroundings. • Unresponsive: no verbal, or physical response to stimulation

11. THE END