1. Introduction
    (Gather supplies: B/P cuff, stehoscope, penlight, DTR hammer, Thermometer, watch, black pen)
    • a)wash hands
    • b)introduce self(hi I am John, I will be your SN today)
    • c) Idenify client by name and arm band
    • d)Explain Procedure(I will be doing a head to toe examination today)
    • e)Provide Privacy
  2. General Survey
    • a) saftey concerns
    • b) physical appearence and body structure
    • c) Motor Activity (gait, balance, posture)
    • d)A&O (person, place, time, event)
    • e)Dress, grooming, hygeine
    • f) client mood, affect, and speech
    • g) Vital Signs(Pulse, Resp, B/P, Temp)
    • h) Inquire about pain, pain rating 0-10
  3. Upper Extremeites
    • S: Inquire about changes in skin and problems with movement
    • O: Inspect ROM
    • O: Inspect skin for color & lesions
    • O: Inspect finger nails for brittlness & color
    • O: Palpate Capillary Refill (<3 sec)
    • O: Palpate Skin for Temp & Mositure
    • O: Palpate radial/brachial pulses bilateral for rate/rhythm, volume
    • O: Palpate strength of hand grips
  4. Head/Face
    • S: Inquire about vision, hearing, HA, dizziness
    • O: Inspect facial features for symmetry
    • O: Inspect eyes for PERRLA
    • O: Inspect mouth, tounge, muscous membranes for color, lesiosn
    • O: Inspect movement of soft palate and uvula
    • O: Palpate Lymph Npdes(occipital, postauricular, preauricular, submandibular, submental), for tenderness or enlargment
  5. Neck
    • S: Inquire about stiffness or tenderness in upper neck or back
    • O: Inspect lower neck for fullness, swallowing, trachial position
    • O: Palpate anterior and posterior cervical and supraclavicular lymph nodes
  6. Thorax
    • S: Inquire about troubled breathing, cough, chest pain, palpitations(fluttering)
    • O: Inspect skin color, lesions anterior and posterior
    • O: Palpate skin turgor(<3sec) over upper chest
    • O: Ausculate anterior, posterior, lateral breath sounds
    • O: Ausculate hear sounds(location, sounds heard)
    • O: Compare Apical pulse rate/rhythm to radial pulse
  7. Abdomen
    • S: Inquire about N/V/D, constipation or pain
    • S: Inquire about changes in bowel or bladder function
    • O: Inspect skin color, lesions, scars, bulges, pulsations, and distention
    • O: Ausculate for bowel sounds in 4 quadrants
    • O: Percuss systematically in all four quadrants(note sounds: tympanny normal)
    • O: Palpate systematically in all quadrants for consistency, tenderness
  8. Lower Extremities
    • S: Inquire about changes in skin and prolems with movement
    • O: Inspect ROM
    • O: Inspect skin for color, lesions
    • O: Palpate for Temp and Mositure
    • O: Palpate toe nails for cap refill(<3sec)
    • O: Palpate posterior tibial and dorsalis pedis bilaterally
    • O: Palpate for Edmea
    • O: Percuss patellar DTR bilaterally
Card Set
head to toe assessment