Head to Toe Assessment

Head

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

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

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

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

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

Skin Color

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

Mental Status

      Orientation: Name Day of week Date Who is president Situation: If other assessments are negative.

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

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THE END