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Head-to-Toe Beginners Assessment (begin with vital signs)

Alert and Oriented times person, place, time. (A&O x 1,2,3)
Responds appropriately, inappropriately?
Confused? Re-orients.
Pupil size and reactivity (1mm,2mm etc./brisk, sluggish, fixed/dilated)
Facial Symmetry- observe, have patient smile. Does one side of mouth or face droop?
Moves all extremities. MAE x4. Numbness? Pain-Pain Scale?
Have pt. grip your hands and lift feet- check for weakness
Wheelchair? Walker? Cane?
Skin warm, cool, hot? (be sure to note extremities- not just centrally)
Skin dry, moist, diaphoretic (extremities as well)
Skin color- pink, pale, brown, yellow, mottled
Wounds? Rash? Bruising?
Bilateral Breath sounds clear all lobes, even and unlabored? Shallow? Deep? Labored?
Crackles, wheezes, rhonchi, Cheyenne-Stokes?
See-saw or uneven respirations (pneumothorax)
Type of oxygen delivery and amount or on room air? Chest Tubes present?
Peripheral pulses- radial, pedal, posterior tibial, popliteal +1,+2,+3 (weak-bounding)
Capillary refill < 3 sec.
Edema present 1 4 pitting? JVD? (Jugular venous distention)
Heart Sounds S1S2 try to listen for extra sounds Listen at all 5 points
Shape of abdomen- flat, round, obese, firm, distended?
Bowel sounds in all 4 quadrants (BS + x 4 quads) active, hypoactive, hyperactive, absent?
Nutrition eating? What percentage of meals? Tube Feedings?
Last bowel movement diarrhea, constipation, blood in stool?
Urinary output. Amount, color, clarity, sediments, odor
Difficulty or unable to void. Signs/symptoms of infection?
In a brief assessment genitalia can be deferred unless there is a problem or your patient is OB/GYN or prostate
surgery etc..
Laughing, smiling, talkative, crying? Family or support system?
Ex. What could you teach the patient/family in order to help that patient live more independently?
07/21/10 1730 Shift assessment completed. VS: Temp 98.6 (O), AP 80 reg., RR 14, B/P 148/80. Pupils 2mm, brisk. MAE x 4
with weakness noted bilaterally in the lower extremities. Grip strength = strong . Pain 0 on 0 10 scale. Skin is pink, warm and
dry. 3 cm. bruise noted on right thigh. Sacral area reddened. Will speak to wound RN about frequent repositioning and use of
protective skin barrier cream. Breath sounds clear and un-labored, diminished in bases. S1-S2 present and regular. No
murmurs noted. Radial pulses, pedal pulses, posterior tibial (RP, DP, PT) +2 bilaterally with capillary refill < 3 sec.. +1
dependent edema noted bilaterally MD aware. (NOTE: be sure and check doctors notes to make sure he IS aware even if
another nurse told you he know about it!) Abdomen flat, soft BS + x 4 quads. Pt. states she is eating well about 90% of
regular diet. Her last BM was yesterday and she states she didnt quite make it to the toilet. Urinating without difficulty
although patient states I sometimes cant make it to the bathroom in time and wet myself. Ambulates with walker. Smiles
and laughs often. Will talk to patient about wearing adult briefs to help with her incontinence problem. B. Pauley RN
07/21/10 1830 Spoke with patient regarding the use of adult briefs. Pt. states she would like to give them a try. Also spoke
with MD about potential area of skin breakdown and obtained order for consult with wound nurse. Nurse will schedule visit for
tomorrow 07/22/10. B. Pauley RN