Head to toe assessment

Head to Toe Assessment
Outline
INTRODUCTION:
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Check the Vitals: Temperature, Heart
Rate, Blood Pressure, Respiratory Rate,
O2
PAIN: OPQRST
o O – onset
o P – palliating factors
o Q – quality
o R – region and radiation
o S – severity
o T – treatment
Check for Level of Consciousness
(LOC):
– Ask for the person’s name, where are
they, when is the date and time, and
their current situation
HEAD:
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MOUTH: check the oral mucosa,
tongue, gums
EYES: PERRLA (pupil, equal, round,
reactive to light, and accommodation)
NECK VEINS: either flat or distended
HEART:
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Check for apical pulse rate and rhythm
Check for telemetry rhythm
LUNGS:
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Auscultate lungs front and back
Define depth, rate, and sound
GI/GU (Gastrointestinal and Genitourinary):
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Auscultate bowel sounds on the
abdomen quadrants: Right Lower
Quadrant, Right Upper Quadrant, Left
Upper Quadrant, Left Lower Quadrants
Palpate abdomen and define if it’s soft,
hard, or distended
Inspect for infection and/or
inflammation
Check for last bowel movement and void
(frequency, foley, discharge, and pain)
SKIN:
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Assess skin color, temperature, clean,
dry, and intact
Check for pulses (0: absent; +1: weak;
+2: normal; +3: increased; +4:
bounding)
Check if there is peripheral edema
Check for capillary refill (