SCREENING-HEAD TO TOE ASSESSMENT: BASIC FRAMEWORK

General Survey
A general first impression. May include the following:
General Status:
-Level of consciousness, orientation
-Affect
-Speech
-Body Movements -
Stature
-Personal Hygiene
Assessment
Vital signs: Temp, pulse, RR, BP, 02 sat.
Integument: Skin: color, turgor, temperature, moisture, lesions
Neurological: -Appropriateness of response, speech, affect
-Visual acuity
-Pupils (PERRLA)
-Gait, handgrips, moves all extremities equally?
-Other neuro deficits (facial drooping, etc)
Pain: location, rating (0-10), FACES pain rating scale

-Apical pulse (auscultate for S1 and S2, rate and rhythm in all
Cardiovascular:
areas)
-Peripheral pulses bilaterally (strength and equity) -Calf
tenderness -Edema (area/degree) -Capillary refill

-Observe excursion (effort/symmetry), respiratory

rate/rhythm/depth
-Auscultate anterior & posterior lung sounds
Respiratory:
-mouth: condition of teeth, moisture and color of
mucous membranes, dentures
-Abdomen: inspect shape, auscultate bowel sounds,
Gastrointestinal: palpate and assess for distension, tenderness,
masses

-Elimination: urine output, color, burning, observe and

palpate for distended bladder, penile or vaginal drainage,
sexual concerns.
Genito-urinary:

Musculoskeletal: Range of motion, muscle strength Cultural,

Psychosocial, Spiritual concerns:

Equipment: IVs, NG, foley, etc.