ETABLE 3-2

eTABLE 3-2

HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLIST

PERFORMED NOTES OR COMMENTS

PREPARATION OR ACTIVITY General Survey: Observe General State of Health with Patient Seated
1. Assemble all equipment and supplies.

Procedure
2. Explain to the patient what you are going to do, why it is necessary, and how he or she can cooperate. 3. Wash hands and observe other appropriate infection control procedures. 4. Provide for patient privacy.

Record Findings for

Body features State of consciousness and arousal Speech Body movements and carriage Physical appearance Nutritional status Stature

Vital Signs Record Findings for

Blood pressureboth arms for comparison Apical/radial pulse Respiration Temperature Height and weight Body mass index (BMI) calculation

Integument Inspect and Palpate Skin for

Color Breakdown, lacerations, lesions Scars, tattoos, piercings Bruises, rash Edema Moisture Texture Temperature Turgor Vascularity

Inspect and Palpate Nails for

Color Lesions Size Flexibility Shape Angle Capillary rell time

Head and Neck Inspect and Palpate Head for

Shape and symmetry of skull Masses Tenderness Hair Scalp Skin Temporal arteries Temporomandibular joint Sensory (cranial nerve [CN] V, light touch, pain) Motor (CN VII, shows teeth, purses lips, raises eyebrows) Looks up, wrinkles forehead (CN VII) Raises shoulders against resistance (CN XI)

Inspect, Palpate, Auscultate Neck for

Skin (vascularity and visible pulsations) Symmetry Postural alignment Continued
Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.

ETABLE 3-2
HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLISTcontd
PERFORMED NOTES OR COMMENTS

eTABLE 3-2

PREPARATION OR ACTIVITY Inspect, Palpate, Auscultate Neck forcontd

Range of motion Pulses and bruits (carotid) Midline structure (trachea, thyroid gland, cartilage) Lymph nodes (preauricular, postauricular, occipital, mandibular, tonsillar, submental, anterior and posterior cervical, infraclavicular, supraclavicular)

Inspect, Assess, Palpate Eyes for

Visual acuity Eyebrows Position and movement of eyelids (CN VII) Visual elds Extraocular movements (CN III, IV, VI) Cornea, sclera, conjunctiva Pupillary response (CN III) Red reex Eyeball tension

Inspect, Palpate Nose and Sinuses for

External nose: shape, blockage Internal nose: patency of nasal passages, shape, turbinates or polyps, discharge Frontal and maxillary sinuses

Inspect, Assess, Palpate Ears for

Placement Pinna Auditory acuity (Weber or Rinne test, whispered voice, ticking watch) (CN VIII) Mastoid process Auditory canal Tympanic membrane

Inspect, Assess, Palpate Mouth for

Lips (symmetry, lesions, color) Buccal mucosa (Stensens and Whartons ducts) Teeth (absence, state of repair, color) Gums (color, receding from teeth) Tongue for strength (asymmetry, ability to stick out tongue, side to side, fasciculations) (CN XII) Palates Tonsils and pillars Uvular elevation (CN IX) Posterior pharynx Gag reex (CN IX and X) Jaw strength (CN V) Moisture Color Floor of mouth

Extremities Observe Size and Shape, Symmetry and Deformity, Involuntary Movements; Inspect and Palpate Arms, Fingers, Wrists, Elbows, Shoulders for
Strength Range of motion Crepitus Joint pain Swelling Fluid Pulses (brachial, radial) Test reexes Biceps Patellar Triceps Achilles Brachioradialis Plantar

Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.

ETABLE 3-2
eTABLE 3-2

HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLISTcontd

PERFORMED NOTES OR COMMENTS

PREPARATION OR ACTIVITY Inspect and Palpate Legs for

Strength of hips Edema Hair distribution Pulses (dorsalis pedis, posterior tibialis)

Posterior Thorax Inspect for Muscular Development, Respiratory Movement, Approximation of Anteroposterior Diameter
Palpate for symmetry of respiratory movement, tenderness of costovertebral angle, spinous processes, tumors or swelling, tactile fremitus. Percuss for pulmonary resonance. Auscultate for breath sounds. Auscultate for egophony, bronchophony, and whispered pectoriloquy.

Anterior Thorax
Assess breasts for conguration, symmetry, dimpling of skin. Assess nipples for rash, direction, inversion, retraction. Initiate teaching or review of breast self-examination. Inspect for apical impulse, other precordial pulsations. Palpate the apical impulse and the precordium for thrills, lifts, heaves, tenderness. Inspect neck for venous distention, pulsations, waves. Palpate the lymph nodes in the subclavian, central axillary, and brachial areas. Palpate breasts. Auscultate for rate and rhythm, character of S1 and S2 heart sounds in the aortic, pulmonic, Erbs point, tricuspid, and mitral areas; bruits at carotid, epigastrium; breath sounds at right middle lobe.

Abdomen
Inspect for scars, shape, symmetry, bulging, muscular position and condition of umbilicus, movements (respiratory, pulsations, presence of peristaltic waves). Auscultate for peristalsis, bruits. Palpate to conrm positive ndings; check liver (size, surface contour, tenderness); spleen; kidney (size, contour, consistency, tenderness); urinary bladder (distention); femoral pulses; inguinofemoral nodes; and abdominal aorta.

Completion of Examinations of Extremities Observe the Following

Range of motion of hips, knees, ankles, feet Crepitus Joint pain Swelling Fluid Muscle development Coordination (heel to shin) Proprioception (position sense of great toe)

Neurologic System Motor Status Observations

Gait Toe walk Heel walk Drift

Coordination
Finger to nose Romberg sign Heel to opposite shin Spine (scoliosis) Continued

Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.

ETABLE 3-2
HEAD-TO-TOE (TOTAL BODY) ASSESSMENT CHECKLISTcontd
PERFORMED NOTES OR COMMENTS

eTABLE 3-2

PREPARATION OR ACTIVITY Genitalia* Male External Genitalia

Inspect penis, noting hair distribution, prepuce, glans, urethral meatus, scars, ulcers, eruptions, structural alterations, discharge. Inspect epidermis of perineum, rectum. Inspect skin of scrotum; palpate for descended testes, masses, pain.

Female External Genitalia

Inspect hair distribution; mons pubis, labia (minora and majora); urethral meatus; Bartholins, urethral, and Skenes glands (may also be palpated, if indicated); introitus; any discharge. Assess for presence of cystocele, prolapse. Inspect perineum and rectum.
*If the nurse has the appropriate training, the speculum and bimanual examination of women and the prostate gland examination of men can be performed after this inspection.

Copyright 2011, 2007, 2004, 2000, 1996, 1992, 1987, 1983 by Mosby, Inc., an affiliate of Elsevier Inc.