Head-To-Toe Assessment Template with notes PDF

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Summary

Download Head-To-Toe Assessment Template with notes PDF

Description

1 Level of Consciousness: Awake Alert Restless

Drowsy Sedated Confused

Hair: Clean Dirty Neatly groomed

Evenly distributed Unevenly distributed Thick/Full Sparse/Hair loss

Unkempt

Orientation: Person

Time

Place

Situation

Mentation:

Pleasant

Uncooperative Withdrawn Restless

Angry/Agitated

Anxious

Calm Cooperative

Communication: Verbal Writes notes Mouths words Nods head to yes/no questions

Vitals: Temperature: Pulse: Respirations: Blood Pressure: Pulse ox: % Via:

Pain: No Yes Location: Intensity: 0 1 2 3 4 5 6 7 8 9 10 Quality: Aggravating Factors: Alleviating Factors:

Eyes: Conjunctiva: Pink Moist Sclera: White Intact

Intact Other:

Other:

Abnormal Discharge: Yes: No Pupils: Equal Round

Reactive to light Accommodating

Abnormal Findings: Pinpoint Unequal: R>L or L>R Fixed

Nose: Midline Symmetrical Congestion

Lesions: Other:

Sneezing

Ears: Symmerical Skin Intact Lesions:

Duration/Frequency:

Skin intact

Hearing Devices:

Earwax/Discharge:

2 Mouth:

Abdomen:

Mucosa: Pink

Sores

Moist Dry

Other:

Inspection: Symmetrical Other:

Bowel Sounds: RLQ: active / hyperactive / absent

Neck:

RUQ: active / hyperactive / absent

Symmetrical

LUQ: active / hyperactive / absent LLQ: active / hyperactive / absent

Lumps/bumps: Range of motion:

Palpation: Soft

Chest:

Tender

Inspection:

Firm Hard

Symmetrical

Other:

Apical Heart Rate:

Beats per minute

Rhythm: Regular

Shoulder shrug: strong / weak / unable Grip strength: Range of motion: Capillary refill: Radial pulse:

Irregular Heart Sounds: Normal/Distinct

Murmur

Distant Muffled

Extra sounds Gallop

Breath Sounds:

Lower Extremities: Pedal push: strong / weak / unable Range of motion: Capillary r efill: Edema:

Decreased Absent

Skin:

Wheezing

Temperature: hot / warm / cool / cold Moisture: clammy / diaphoretic/ dry Turgor: elastic / tented / edema Color:

Respiratory Rhythm: Regular

Distended Flat Rigid Guarding pain

Upper Extremities:

Round/Convex

Clear Crackles

Rounded

Irregular

Depth: Unlabored Accessory muscle use

Pressure ulcer: Deep Shallow

Wound:...