Head to Toe Assessment

It is possible to do head to toe assessment in less than 5 minutes without missing anything along the way. Start from the head and end at the toes and you'll be sure you don't miss anything.

1. level of consciousness (LOC) : is this person alert? drowsy? lethargic?
2. Head

• Head: check for any abrasions, lice, bumps, etc
• eyes: check for PERRLA (Pupils Equal and Round and Reactive to Light and Accomodation)
• nose
• mouth

check inside the mouth for any mouth sores 

3. Neck  

• lymph node ( is it swollen?)
• jugular vein distention ( JVD)

4.  Arms

• Cap refill ( fingernails; does it refill in 3 secs. or less?)
• hand grip 
• radial pulse
• ROM, strength

5. chest

• respiration (shallow?regular?irregular? normal respiratory rate: 12-20 breaths per min)
• skin turgor( does the skin tent up? to assess patient's hydration status)
• apical pulse( left mid clavicular, 5th intercostal space.)
• lung sounds

6. abdomen

• abdominal exam ( bowel sound) : inspect, auscultate, palate.
• BM
• Pain

7. GU

• bladder distention

8. Legs 

• pedal pulse (check dorsalis pedis)
• edema
• Homan's sign ( ask patient to dorsiflex their feet while you hold their calf. If sharp pain is present, there's a possible deep vein thrombosis)
• cap refill . ( for the toenails)
•  ROM

* Throughout the assessment process, inspect the skin.