Performing a Head to Toe Assessment

Performance Behaviors

Assess level of consciousness and orientation

• Person

• Place

• Time

Assess and Compare Bilateral Upper Extremities

• Hand grasps for equality and strength• Temperature and color• Radial pulses• Capillary refill• Sensation

Assess Apical Pulse

• Auscultate heart sounds at point of maximal impulse (PMI).

• Listen for one minute, noting rate and regularity.

• http://www.practicalclinicalskills.com/auscultation-lesson-description.aspx?coursecaseorder=1&courseid=22

Heart Sounds

Assess Lungs

• Listen and observe rise and fall of chest and count respirations

• Auscultate breath soundsAssess anterior chest in 4 sites and 2 lateral sitesAssess posterior chest in 4 sites and 2 lateral sites

Lung Sounds