Head to Toe assessment questions

Question 1

How do you record pain?

Answer 1

on a scale of 1-10

Question 2

What are the vital signs?

Answer 2

A. Temperature
1. Look at lips – color, moist, dry, cracked?
2. Check mouth, teeth, gums – color, moisture, lesions or bleeding
3. Note face coloring - pale, ashen, sallow, cyanotic, pink, flushed or jaundiced
4. Does skin of face look moist or dry?
5. Facial muscles - Do they move symmetrically?
6. Eyes (or later if desired)
a) PERRLA
b) Assess sclera and conjunctiva
B. Pulse
1. Listen to apical pulse. Palpate radial pulse.
a) Is it regular or irregular? Describe irregularities.
b) Are heart tones strong, weak, distant, muffled or faint
2. Note skin color, temperature, moisture, turgor
3. Check nail beds – color, speed of capillary refill
4. Assess IV site - Any signs of infiltration or inflammation? All tubing intact
and connected? IV infusing?
5. May assess hand grasps now or later
C. Respirations .
1. Characteristics
a) Rate of respirations – even or irregular
b) Depth of respirations - shallow, deep or normal
c) Describe any unusual respiratory patterns
d) Ease of respirations - easy, regular, quiet, labored or orthopneic
dyspneic?
2. Breath Sounds
a) Normal or diminished? If diminished, where?
b) Clear, rales, rhonchi, wheezes or friction rub? Do any abnormal sounds
clear with coughing?
c) Does the patient have a cough? If so,
(1) Frequency of coughing: Occasional, frequent, paroxysms,
continuous?
(2) Sound of cough: Moist, dry, harsh or rasping
(3) Productive or non-productive? If productive, amount, color,
consistency of mucus?

.

d) Use of Oxygen
(1) Mask administration?
(2) Or nasal cannula?
(a) Is cannula properly placed?
(b) Any irritation of ears or nares from nasal cannula?

D. Blood Pressure

Question 3

How do you describe bowel sounds?

Answer 3

Absent, hypoactive, active, hyperactive

Question 4

How do you describe abdomen shape?

Answer 4

flat, rounded, distended, soft, firm, taut?

Question 5

What do we record about urine?

Answer 5

COD
Color, odor, drainage
(clarity, also amount of urine)
60cc/hr is the miinimum
note any unusual odor

Question 6

How do we assess extremities’ strength?

Answer 6

assess foot push/pull

Question 7

How do we assess coordination?

Answer 7

• gait test

- check if movements are fluid and coordinated

Question 8

How do we assess circulatory status in feet, legs, arms, and hands?

Answer 8

color, temperature, capillary refill, pulses, edema

also. ..
1. . Also notice if skin is dry, flaking, oily, supple, fragile
2. Edema - feet, ankles, legs, arms, sacrum? - 0 to 4+
3. Pedal pulse - present bilaterally? quality - 0 to 3+
4. Sensation - numbness, burning, tingling? Describe any unusual sensations,

Question 9

What do we record about dressings?

Answer 9

is it dry or drainage present. If so describe: COAT
C: color (serous sanguinous – red/purulent – whitish yellow pus)
O: odor (foul or the scent with purulent)
A: amount (copious, scant)
T: time of last dressing change and the current time
-make sure to note the dimensions of the wound
-unapproximated: is anything changed in the wound that wasn’t the initial incision
-approximated: is the incision

Question 10

What do we record about drains?

Answer 10

if present what kind?

amount and color of drainage

Question 11

What do we record about suture lines?

Answer 11

staples present? if so are edges approximated? describe drainage or signs of inflammation

Question 12

What do we record about the NG/gastric/or jejunostomy tubes?

Answer 12

Check condition of insertion site, patency (openess) of tube, if suction is used, describe frequency and strength

Question 13

What do we record about the colostomy or ileostomy?

Answer 13

check condition of stoma and skin. assess drainage (amount, color, consistency)

Question 14

What do we record from the neurological/mentation assessment?

Answer 14

A. Orientation - to person, place, time
B.· Level of consciousness - alert, lethargic, stuporous or comatose
C. Responsiveness - Does pt. respond immediately? Can he follow
directions? Are comments appropriate? Is he confused?
D. Pupil response -size; PERRLA
E. Grasp - strong, firm, weak? equal or unequal?
F. Foot push/pull- strong, weak? equal or unequal?
-describe overall mood

Question 15

What do we record in the general assessment?

Answer 15

Introduce self & explain purpose of assessment
General level of awareness / alertness
Orientation to place & time
Query regarding+/- of pain or difficulty breathing
Overall tone and facial symmetry
Skin color/tone/temperature

Question 16

What do we record during the assessment of eye function (cranial nerve)?

Answer 16

Approximate size of pupils in mms.
Are pupils equal in size?
Are pupils appropriate for the amount of light in the room?
Assess pupillary constriction (direct only) - PERRL

Question 17

What does PERRL stand for?

Answer 17

Pupils equal round and reactive to light

Question 18

How is the thorax assessment done?

Answer 18

Auscultate: (Remember to instruct patient re: proper positioning and
breathing!
Breath sounds posteriorly
Breath sounds anteriorly

Question 19

How is the cardiac function assessment done?

Answer 19

Auscultate: (sites)
Aortic 
Pulmonic 
Erb's 
Tricuspid 
Mitral

Question 20

How is the assessment of gastrointestinal function done?

Answer 20

Inspect for: 
Contour 
Auscultate for: Bowel sounds in all four quadrants 
Palpate: 
Lightly in all four quadrants 
Deeply in all four quadrants

Question 21

How is the assessment of peripheral vascular function done and what is recorded?

Answer 21

Palpate:
Capillary refill
Radial pulses
Dorsalis pedis pulses

Question 22

What is done and recorded in the assessment of neuro/musculoskeletal function?

Answer 22

Symmetric hand grip (bilaterally)
Leg lift against resistance (bilaterally)
Patellar, DTR (bilaterally)