Head to Toe Assessment (Part 1)

Question 1

Introduction

Answer 1

• I’m going to wash my hands.
• I am going to introduce myself (Introduce yourself)
• I’m going to check the patient’s identification. Can I check your bracelet? What is your name and date of birth?
• I’m now going to close the curtain for privacy.

Question 1

1 I’m going to assess the patient’s PHYSICAL APPEARANCE.

Answer 1

• The patient looks their stated age, is alert, oriented, and shows no signs of acute distress.

Question 2

2 I’m going to assess the patient’s BODY STRUCTURE.

Answer 2

• The patient’s height & weight appear normal for their age, and THEIR POSTURE IS ERECT.

Question 3

3 I’m going to assess the patient’s MOBILITY.

Answer 3

When the patient walked into the room, their gait was:
- SMOOTH
- COORDINATED
- And there’s no evidence of involuntary movements.

Question 4

4 I’m going to assess the patient’s BEHAVIOR.

Answer 4

The patient maintains:
- EYE contact
- their FACIAL expressions are appropriate
- their SPEECH is clear
- and their HYGIENE/GROOMING is appropriate for the weather.

Question 5

5 I’m going to assess for pain.

Answer 5

• Are you feeling any pain?
• (If yes): On a scale from 0-10, how would you rate your pain?

Question 6

6 I’m going to assess the patient’s mental status, ORIENTATION, LEVEL OF CONSCIOUSNESS, and MEMORY.

Answer 6

• Can you tell me your NAME?
• Can you tell me WHERE you are?
• Can you tell me what TIME it is?
• Can you tell me was you had for DINNER last night?

The patient was ALERT and ORIENTED to PERSON, PLACE, and TIME & their SHORT-TERM MEMORY is intact.