Head-to-Toe Assessment Cheat Sheet

Norma Gail Yearick, MSN, RN

General Survey:

 Observe and note gender & race, age, signs of distress, body type, hygiene & grooming, dress,
body odor, affect & mood, speech, and signs of physical and/or substance abuse.
 Mental status = alertness and orientation to person, place, time, and situation.
 Vital signs = temperature, pulse, respirations, blood pressure, & oxygen saturation.
 Skin = color, temperature, lesions, turgor.

Head:

 Eyes
o Sclera (color)
o Conjunctiva (color & moistness)
o Pupils (equally round, reactive to light, and accommodating)
o Vision (Snellen chart, glasses or contacts)
 Ears
o Appearance (discharge, wax)
o Hearing (whisper test, hearing aids, ability)
 Mouth
o Lips (cracks & lesions)
o Oral Mucosa (color, moistness, lesions)
o Teeth (dental caries, cracks, missing teeth, dentures)

Cardiac

 Pulse Points (carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial)
 Heart Sounds
o Regular or irregular
o S1 = left fifth intercostal space (mitral valve)
o S2 = right second intercostal space (aortic
o S1 and S2 = one heartbeat
o Abnormal sounds (murmur, clicks, rubs)
 Capillary Refill
o Return to pink in < 3 seconds after pinching skin = good capillary refill.
 Edema (trace, +1, +2, +3, +4)
 Skin Color
 Skin Temperature
o Feel with back of hand; should be symmetrical)

Respiratory
  Inspection
 Chest shape; accessory muscle use; chest excursion
 Breathing Pattern
 Auscultation (26 auscultation points = 8 anterior, 4 lateral, and 10 posterior)
 Abnormal Sounds = rales (crackles), rhonci, wheezes, pleural friction rub

Abdomen

 Inspection (contour)
 Auscultation
o 4 quadrants; umbilicus is center of each quadrant
o Should hear bowel sound within 5 to 20 seconds
o If no bowel sound in 5 minutes = bowel sounds are absent = problem!
 Palpation
o Lightly palpate each of the 4 quadrants
o Feel for masses, pulsations, and complaints of pain

Gastrointestinal & Genitourinary

 Bowel habits & characteristics

 Voiding habits & characteristics

Skin

 Check pressure points

o Bony prominences
 Legs
o Shins for ulcers