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
Strength
Sensation Tremor
Head/ Neck WNL Flaccid Spastic WNL To pain No response to
pain
No Present
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:
WNL (60-100)
Bradycardia
Tachycardia
(Extremely low or high HRs
decrease C.O., blood and O2
to the vital organs).

Apical/ radial deficit: No Yes
Heart sounds:
Normal S
1
S
2
S
3
(gallop)
Valve click [artificial heart valve]
Murmur:
Holosystolic
Midsystolic
Diastolic

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): ____________________ Clients explanation of bruising: _________________________________________

Wounds
Location Type Size Tunneling Undermining Surrounding
Tissue
Drainage

Abrasion
Avulsion
Burn
Laceration
Puncture
Pressure ulcer,
Stage _________
Stasis ulcer
Surgical incision,
closed, edges are
approximated
Surgical,
open areas
total wound
dehisence
______________
Length ____
cm

Width ____ cm

Depth ____ cm


Incision length
___________
cm

_______ # of
staples/
sutures
(circle one)
None

Present at
_____ oclock,
depth ______
cm


Present at
_____ oclock,
depth ______
cm

None

Present,
surrounding
tissue is:
Dusky
Soft
Boggy
Fluid-full
Other,
describe:


WNL

Redness
Tenderness
Pain
Warmth
Streaking
Excoriation
Bruising
Discolored
Dusky

Wound edges
WNL
Hyperkeratotic

Color/
Characteristics:
Serous
Serosanguinous
Bloody
Yellow
Tan
Brown
Green

Purulent?
No Yes

Odor?
No Yes

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 DCd 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 (Brocas) patient understands, can respond w/ great difficulty in short abbreviated, phrases. Aware and
frustrated. Often frontal lobe damage.
Receptive aphasia (Wernickes) 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:
Notifythe physician of all abnormal findings!!
Use the nursing process to:
o Analyze subjective and objective findings.
o Make a nursing diagnosis.
o Plan and implement appropriate interventions.
o Evaluate 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
As you converse with the patient assess:
* Orientation to person, place, time
* Communication/ speech
* Respiratory effort and rhythm
* On/ off O
2

* Glasgow coma score
* Pain 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 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 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 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 genitalia/ buttocks:
* Skin color, temp,
moisture and integrity
* Incisions and dressings
* Femoral pulses
* Sacral edema
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 3
rd
beat is a VPB] Quadrigeminy [every 4
th
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.