Head-to-Toe Sheet
INSPECTION PALPATION AUSCULTATE PERCUSSION
Wash Hands (2 minutes)
Introduce Self (“Hi my name is…, Student LVN @ Carrington college”)
Identify pt/check wrist band
Observe room/equipment function
General appearance “Clean, Dress appropriate for occasion”
Signs of acute distress: s/s retractions or nasal flaring.
Signs of accessory muscle use.
Questions/General Survey
LOC/Orientation
o Do you know where you are?
o What are you here for
o What is today’s date?
o Remote/Recent Memory?
o Verbalize Alert & Oriented x 4
“I’m going to begin the assessment. Do you need to use the restroom
before we begin?”
“Are you experiencing any SOB? Any difficulty breathing?”
“Any cough? Any phlegm?”
“Can you rate your pain 0-10?”
“Are you experiencing any nausea or vomiting?
“Are you passing gas?”
“When was your last bowel movement?”
“Experiencing Diarrhea? Constipation?”
“Experiencing any bowel incontinence? Urinary incontinence?”
“How many times do you urinate in a day?
“What color is your urine?”
“Do you experience any burning, urgency, or frequency with urination?”
>---------------------------------RAISE BED TO WORKING LEVEL-------------------------------<
Face/Head/Neck
Facial Symmetry
Verbalize Skin color AFR, Moist, and warm
signs of Periorbital edema
CN III, IV, VI (Star w/ Pen)
o Verbalize “EOMS intact w/o nystagmus”
“PERRLA” (Pen light, Accommodation)
o Verbalize “Pupils Equal & Reactive to Light and Accommodate”
CNs IX, X, XII
o CN IX – Client says “AHH” “Uvula rises midline on pronation”
o CN X -- “(+) gag reflex, swallowing intact”
o CN XII – Stick tongue out “ Tongue rises midline w/o tremors”
Tonsils – Verbalize “Tonsils pink 1+. Smooth”
Lips, mucosa, gums, tongue, throat Pink, smooth, moist
Teeth “White aligned, even spacing, decay.”
Neck muscles: “FAROM”
Verbalize “CN VIII (Auditory) intact. Client is able to follow directions &
converses easily”
UE
Skin Turgor under clavicle: “ Tenting”
Capillary refill: “<2 Seconds”
Pulses: “Ulnar: 1+, Radial 2+”
Shoulder/Elbow/Wrist Passive & Resistance ROM: “FAROM”
Grip Strength – Verbalize “Strong Equal”
Elbow strength, Client pulls arms while crosses push/pull “5/5 (B)”
Cardiac/Respiratory
Chest Configuration “Anterior is less than Transverse”
Heart Sounds
o Verbalize “S2>S1 at Base, & S1 >S2 at apex. Heart sounds regular
rate and rhythm”
Anterior/Lateral Lung Sounds
o Verbalize “Breathe in deeply through the mouth and out when I
place my stethoscope so I can best hear your lung sounds”
o Begin at R clavicle area (apices @ C7) to the bases of the lungs at
T10. Listen for complete inspiratory/expiratory cycle.
o Verbalize “CTA throughout”
Resp. Patturn “Breathing is even & Unlabored”
Back
Spinal Alignment/Posture – “Spine is straight and erect”
Posterior/Lateral Lung Sounds.
o Verbalize “Once again, please breathe in deeply through the
mouth and out when I place my stethoscope.”
o Start L then continue inferiorly in ladder movement for complete
inspiratory/expiratory
o Verbalize “CTA throughout”
CVA Tenderness
o Verbalize I am going to percuss your lower back, let me know if
you have any pain”
o Percuss over CVA
o Verbalize “ CVAT” (Costovertebral Angle Tenderness)
Sacral Redness/Edema – “No redness or edema at sacral site”
--------The Rest of the Physical Assessment Will be Done in Supine Position---------
-------------ASK CLIENT TO REMOVE SOCKS AND SHOES BEFORE LYING DOWN-------
Jugular Veins
Supine w/ head looking to the R, bring bed up till JVs are viewed
Verbalize “ JVD @ 45 Degrees”
Abdomen/Elimination/Apical Pulse -
Apical Pulse
o Located at (L) 5th ICS MCL
o Obtain 1-minute apical pulse.
Bowel Sounds – Start at RLQ
o Verbalize Normoactive in all for quadrants
Contour – Inspect Abdomen – Verbalize “Contour is Flat”
Softness/Tenderness/Masses –
o Verbalize “Let me know if you feel any tenderness or pain”
o Verbalize “ masses, abdomen is soft and nontender.”
LE – Ask client to pull up pants to view lower legs – Mats: Hammer, Cotton Ball
Skin color/temp/integrity
o Verbalize “Skin AFR, warm, and intact”
Sensation – Cotton ball – Verbalize “(+) (B)”
Pedal/Pretibial Edema: “No signs of pedal or pretibial edema”
Posterior tibial/Pedal Pulses – “2+ (B), 2+ (B)”
Babinski Reflex – Reflex hammer – “j” shaper from heel to big toe
o Verbalize “ (-) Babinski (B)”
Homans Sign
o Hold clients calf and knee up, Dorsiflex the ankle & ask the client if
they feel pain in their calf. Explain procedure. Repeat on each side.
o Verbalize “ Homans sign (-) (B)”
Hip/Knee/Ankle ROM – Verbalize “FAROM (B)”
Hip/Knee/Ankle Strength – Verbalize “Strength 5/5 (B)”
Affect
Verbalize “Thought Process clear”
Verbalize “Mild anxiety”
CLOSURE
Verbalize the following:
o “Is there anything else I can do for you?
o “Do you have any questions or concerns for me?”
o “Thank you for your time”
o “Bring bed down, Call light w/in reach, Client is perfectly aligned in
bed, One side rail up one side rail down”
WASH HANDS
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