Nursing Brain Head To Toe Assessment
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1Nursing Brain: Head-to-Toe Assessment
Name, Rm, M/F, DOB, LOS
Patient ID
T, HR, BP, RR, O2sat, pain
Vital Signs
Head/Neuro
Alert & Oriented X 3
Speech normal, appropriate
PERRLA
Facial symmetry
Mouth, gums
Equal bilateral hand grips
Neck/Lymph
Nodes esp. subclavian
JVD
Palpate thyroid while swallow
Skin/Hydration
Color, temperature, moisture
Turgor
Lesions, wounds
Ulcers esp. bony prominences
S1, S2, S3, S4, rubs, murmurs
Cardiovascular
Pacemaker
5 heart: aortic, pulmonic,
erb’s, tricuspid, mitral
(APE2man)
Cap. refill fingers and toes
Pulses radial/pedal
Clubbing
Respiration
Percuss chest front and back
Ausc. 5 lobes, adventitious:
crackles, wheezes, rhonchi
Labored breathing
Accessory muscles used
Palpate: crepitus
GI/Abdomen
Last BM
Bowel sounds X 4Q
Palpate for masses, guarding
GU
Last urine: when, qty, color
Legs/Feet
Edema
Homan’s sign
Grip strength, bilateral
Muscle/Skel.
Feet dorsal/plantar flex/extend
Foley
Equipment
Oxygen/ventilator
Suction
IV – loc., condition, last chg
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Parent category: Medical