Head To Toe Assessment

HEAD TO TOE ASSESSMENT

Introduce yourself and take vital signs • BP, pulse rate, RR, O2 sat • Ask about overnight events, how they slept • Ask about changes in breathing or any new symptoms • Ask about current symptoms they have been or are at risk for experiencing related to their condition (e.g. nausea, dizziness, numbness, palpitations, pain) Head/Neck Observe (during vitals or as you are interacting) • General ability to breath easily, level of alertness, ability to answer questions and interact appropriately • Color and condition of their mucosa (mouth and tongue) while they talk or when you put in the thermometer; condition of teeth and presence of dentures or bridges • Head and face for size, shape, symmetry, position, and expression • Ear canals for drainage, hearing aide • External nose for edema, discharge • Eyes for position, alignment of eyes • Ability to hear • Movement of mouth and face while interacting • Skin color and position of trachea Assess/Examine • Examine pupils for shape, size, symmetry reaction to light • Observe skin color and position of trachea • JVD or other pulsations in neck Anterior Chest/Abdomen Observe/Assess • Respiratory effort, use of accessory muscles • Observe for rhythm, depth, and symmetry of chest movement • Observe for cough, note severity and describe output • Note size, symmetry, contour of abdomen Auscultate • Heart sounds • Anterior breath sounds ○ Apices and bases of upper lobe (total 4 spots, 1 cycle each spot unless worried or primary diagnosis) ○ RML breath sounds if able • Bowel sounds x4 quadrants Palpate

• Abdomen x4 quadrants • Chest for AP-lateral diameter Back Observe/Assess • Spinal deformity • Respiratory effort and equal expansion • Pressure areas over shoulders/sacrum Auscultate • Posterior breath sounds: apices of upper and lower lobes, bases of lower lobes (total 6-8 spots, 1 cycle each spot unless worried or primary diagnosis) • RML if not already done Extremities – Arms Observe/Assess • Temperature and moisture (briefly!) • Nails for color, clubbing Palpate • Cap refill • Radial pulses simultaneously • Strength – request pt to squeeze fingers simultaneously Extremities – Legs & Feet Observe/Assess • Temperature and moisture (briefly!) • Nails for color, clubbing Palpate • Cap refill • DP, PT (feel bilateral feet simultaneously) • Strength – request pt to lift feet up toward head against resistance, push down (gas pedal) against resistance • Edema across top of foot, ankles, and up shin (further if needed) When mobilizing patient • Assess ROM – active against resistance preferable but perform passive ROM if pt cannot move • Assess balance (with eyes closed), posture, body alignment, symmetry, gait while standing  walking • Inspect symmetry and shape of muscles and joints