head to toe assessment 1
TRANSCRIPT
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8/14/2019 Head to Toe Assessment 1
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Head-to-Toe Assessment
Name Date
Date of Birth Gender
Height Weight
Vital Signs
Temp Site BP / Site O2 % on
Pulse regular irregular weak 1+ steady 2+ strong +3 bounding 4+
Resp regular irregular labored moderate shallow deep apnea
Pain 1-10 rating PQRST
IV
Location Date Gauge
Tubing Date Signs of infection?
Fluid(s) Infusing Rate Fluid Remaining
HEENT
Head Eyes Ears
Observation Observation Observation
Palpation PERRLA Palpation
Temporal Pulse Vision Hearing
Subjective Data Subjective Data Subjective Data
Level of Consciousness Nose Neck/Throat
Orientation Observation Observation
Person Palpation Lymph Node Palpation
Place Patentcy Carotid Pulse
Time Sense of Smell Range of Motion
Subjective Data Subjective Data Subjective Data
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THORACIC
Chest Cardiac
Observation Observation
Palpation Apical Pulse
Breath Sounds Heart Sounds
Anterior Posterior AAA Bruit
Subjective Data Subjective Data
GI/ABDOMEN
Quadrant Q1 Q2 Q3 Q4
Observation
Auscultation
Percussion
Palpation
Subjective Data
MUSCULO-SKELETAL
Upper Extremities Lower Extremities
Observation Observation
Strength Strength
Pulses Pulses
Cap Refill Cap Refill
Edema Edema
Subjective Data Subjective Data
INTEGUMENT
Moisture Temperature Color
Subjective Data