1. A head to toe assessment will be done as part of your NURS 2500 laboratory experience. You will be asked to complete a head-to toe assessment on the HPS and document the head to toe assessment. You should be able to complete the assessment in 5 minutes and the documentation in 5 minutes. The sequence of the assessment is as follows:
Orientation
Pupils
Oral cavity
Lung sounds, anterior (5 PAIRS) (no posterior) )Stethoscope auscultation sites for S1 & S2
Apical 15 sec.
Radial pulses
Skin assessment
Capillary refill <3 sec.
Hand grasp strength +5 equal
ROM (not to R. arm)
Push/pulls equal/strength
IV site assessment, name IV fluid
Abdomen assess 4 quadrants for bowel sounds
Bowel patterns
Bladder, check foley
Pedal, posterior tibial & cap refill
ROM lower extremities
Foot strength, push/pulls
Homan’s sign
2. This article would be helpful for you to prepare for the head to toe assessment.
Poncar, P. J. (1995). Who has time for a head to toe assessment? Nursing95, 25(3), 59.
On campus:
http://search.epnet.com/login.aspx?direct=true&db=aph&an=9504171951
Off campus:
3. This is the head to toe assessment form utilized in 1401. It may be helpful for you to use this to prepare for the head- to –toe assessment. Bring a copy of the head to toe form with you on the day you will do the HPS assessment skill.
HEAD TO TOE ASSESSMENT NARRATIVE
NURSES’ NOTES INFORMATION FROM
OTHER
SOURCES
(INTERVIEW, CHART)
Orientation
person place
time
Levels of
consciouness
awake alert
confused agitated
lethargic
unresponsive
pleasant
cooperative anxious
withdrawn sad
combative
Speech
verbal
non-verbal slurred
language
barrier
Vision
glasses
contact lenses
Pupils
Size______mm.
equal round
reactive to light
Hearing
hearing
aid: left right
Nasogastric tube
Oxygen
_____L./min.by____________
Oral cavity
moist dry
pink pale
cyanotic
dentures
partials caries
edentulous
Temperature
oral_______F./C/
tympanic
membrane______F./C.
Respirations
rate______/min.
rhythm: even
uneven CBC
depth: shallow
deep unlabored Hemoglobin
dyspnea short of breath
Hematocrit
Cough
RBC
productive
non-productive WBC
sputum: color_____ odor_____ Platelets
consistency_____ amount_____
Shape of thorax EKG
A-P diameter WNL barrel chest
symmetrical
kyphosis
scoliosis lordosis
Breath Sounds
anterior: CTA adventious
posterior: CTA adventious
lateral: CTA adventious
Heart sounds
site:
mitral pulmonic aortic
rate:_____beats/min.
rhythm:
regular irregular
Abdomen
Bowel sounds
RLQ
RUQ LUQ LLQ
normoactive
hypoactive
hyperactive
Soft, non-distended Firm, distened
Flat rounded obese
Gastrostomy tube (PEG)
solution______________
rate________ml./hr
intermittent
continous
residual_______/ml.
Extremities
Color
race/ethnicity
cardiorespiratory
status
Temperature to touch
Moisture
Edema: pitting non-pitting
Capillary refill: (one finger in each
hand) <3 sec.L
<3sec.R
Blood Pressure:______/______LR
Extremities
(contiued)
Peripheral Pulses
radial
strong
equal
palpable/Doppler
rate____/min.
rhythm: regular
irregular
amplitude: ) 1+
2+ 3+
brachial
dorsalis
pedis
posterior
tibial
Venous return
Homan’s sign: L R
varicosities
Sensation:
itching trmors paralysis
numbness
tingling
dressing:_____________
Skin
Color
Temperature
Moisture: diaphoretic desquamation
tending
Condition/location:
ecchymosis(ses)_____________
rash:______________________
macules
papules pustules
vesicles crusts
fissures
ulcers
edema anasarca ascites
Intravenous:
site:__________
solution______________
rate_____________ml./hr.
_____________mcg./kg./hr.
Incision
OTA Dressing
open closed: staples sutures
Steri-strips
approximation
length:__________cm
width:__________
cm
depth:___________cm
drainage: dry
wet: amount________
color__________
consistency________
odor____________
Pressure Ulcer:
location:______________
stage:
I II
III IV
dressing:___________________
ADDITIONAL DATA
Urine
Color
Clarity
Odor
Urine Output:______ml./______hr. BUN
Frequency/Pattern of Voiding
_______times/____-hr. Urinalysis
dysuria urgency hestancy
retention
continent incontinent Urine
C&S
Catheter:
Type__________
Bowel Elimination
Date of last bowel movement:
_____________
Continent incontinent
Color
Odor
Consistency
Amount
Hemoccult: Postive Negitive
Nutritional Status serum
glucose
Weight________lb.kg. albumin
Height________in./cm transferrin
Ideal body Weight________lb./kg. lymphocytes
Diet:___________________ cholestrol
Appetite:___________%
eaten Total
Fluid intake:__________ml./hr. LDL
HDL
K+
Na+
Ca++
Cl-
Pain: Yes______ No______
Location:________________ PRN pain meds
Provacative/palliative
Quality/quanity
Region/radiation
Severity
Timing
Activities of Daily
Living
Gait:steady unsteady
ROM: full limited
Bathing : S
A T
Grooming: S A
T
Feeding: S A
T
Toileting: S A
T
Transfer: S A
T
Equipment (list)
Assistive
ambulatory devices
TED
hose
PAS compression stockings
Braces, slings
Heel/elbow protectors
Social, Cultural,
Developmental
Interaction with:
Significant other
Health care team
Social support:
relatives
friends
church
Socioeconomic status
Cultural group
Religion (see cover page)
Developmental tasks for age group
Assessment form From
6/98 MC rev 06 CD