Head to Toe Assessment
I
General Appearance Vital Signs Upper Extremities P = PUPILs
E= Equal
INSPECT R= Round
Inspect • Weight/height/ BMI
RL= React to Light
• BP/ skin Integrity -skin color/condition, lesions
• appearance -symmetry in size & contour A= Accommodation
• Rate, rhythm, depth of
• Skin color radial pulse/ capillary refill -joints, edema Awareness
• Posture • Res. Rate/ Characteristics -condition of fingernails Time
• Oxygen/ Pain level
• body language PALPATE Place
• Mobility -upper arms down to hands Person
-skin temp, texture, moisture
• Mood Neck -brachial/radial pulse
Situation
• Mental status -capillary refill in both hands
INSPECT
• Speech -trachea located midline -shoulder, elbow, wrists finger joints for
-lumps, lesions, trauma Warmth, tenderness, irregularity
Head & Face -ability to swallow
-ROM Observe/ Compare ROM/bilateral strength
Inspect -resistance
-shape, color, symmetry, -Carotid arteries,distended veins
lesions, inflammation PALPATE
Palpate -Carotid pulse
Posterior/Lateral Chest Breathing Sounds
-temporomandibular joint for Pericardial Friction Rub =
pain, crepitus, movement INSPECT High pitched
-outer ear/mastoid for Scratching, grating or
-chest shape, symmetry, muscle, squeaking leathery
localized tenderness
motion, accessory muscle sounds at left Sternal
boarder
AUSCULATE Heart Murmur = swishing
Anterior Chest • begin at C7, move 5cm (2in) or whistling sound.
Rhonchi= snoring sound
Inspect down
-90 degree or less • Finish in axillary/midaxillary lines
-PMI(left midclavicular line @ 5th intercostal)
-shape, symmetry Barrel chest = lung disease
-breast/nipple color, symmetry, skin, edema,
rashes, lumps
-axillary for lumps, rashes, pigments
ABDOMEN Positions
Auscultate
-begin at Inspect-ausc-palp-prec Supine =relaxation of abs
aortic= 2nd inter space on right side INSPECT Dorsal
Pulmonary= 2nd intercoastal left of the sternum -color, skin, lesions, distended veins, Recumbent=Generalis,
Tricuspid= 5th intercoastal left of the sternum pulsation, contour, shape, symmetry,
Mitral= 5th inter space left chest peristalsis, large veins Rectum , Catheter
AUSCULTATE Sims= rectum, vagina
—RLQ Prone= hip joint, posterior
-5 min. Thorax
PALPATE
-for tone and tender areas Lithotomy= Female genitalia
-painful area last rectum, papsmear
Knee chest= rectum & anus
LOWER EXTREMITIES
_ INSPECT
-skin color, condition, lesions, hair distribution, venous
distention, symmetry and contour, toe nails
PALPATE
-thighs down to feet
-temp, texture,moisture, tenderness
-posterior tibial & dorsalis pedis pulses bilaterall
-capillary on both feet
I
General Appearance Vital Signs Upper Extremities P = PUPILs
E= Equal
INSPECT R= Round
Inspect • Weight/height/ BMI
RL= React to Light
• BP/ skin Integrity -skin color/condition, lesions
• appearance -symmetry in size & contour A= Accommodation
• Rate, rhythm, depth of
• Skin color radial pulse/ capillary refill -joints, edema Awareness
• Posture • Res. Rate/ Characteristics -condition of fingernails Time
• Oxygen/ Pain level
• body language PALPATE Place
• Mobility -upper arms down to hands Person
-skin temp, texture, moisture
• Mood Neck -brachial/radial pulse
Situation
• Mental status -capillary refill in both hands
INSPECT
• Speech -trachea located midline -shoulder, elbow, wrists finger joints for
-lumps, lesions, trauma Warmth, tenderness, irregularity
Head & Face -ability to swallow
-ROM Observe/ Compare ROM/bilateral strength
Inspect -resistance
-shape, color, symmetry, -Carotid arteries,distended veins
lesions, inflammation PALPATE
Palpate -Carotid pulse
Posterior/Lateral Chest Breathing Sounds
-temporomandibular joint for Pericardial Friction Rub =
pain, crepitus, movement INSPECT High pitched
-outer ear/mastoid for Scratching, grating or
-chest shape, symmetry, muscle, squeaking leathery
localized tenderness
motion, accessory muscle sounds at left Sternal
boarder
AUSCULATE Heart Murmur = swishing
Anterior Chest • begin at C7, move 5cm (2in) or whistling sound.
Rhonchi= snoring sound
Inspect down
-90 degree or less • Finish in axillary/midaxillary lines
-PMI(left midclavicular line @ 5th intercostal)
-shape, symmetry Barrel chest = lung disease
-breast/nipple color, symmetry, skin, edema,
rashes, lumps
-axillary for lumps, rashes, pigments
ABDOMEN Positions
Auscultate
-begin at Inspect-ausc-palp-prec Supine =relaxation of abs
aortic= 2nd inter space on right side INSPECT Dorsal
Pulmonary= 2nd intercoastal left of the sternum -color, skin, lesions, distended veins, Recumbent=Generalis,
Tricuspid= 5th intercoastal left of the sternum pulsation, contour, shape, symmetry,
Mitral= 5th inter space left chest peristalsis, large veins Rectum , Catheter
AUSCULTATE Sims= rectum, vagina
—RLQ Prone= hip joint, posterior
-5 min. Thorax
PALPATE
-for tone and tender areas Lithotomy= Female genitalia
-painful area last rectum, papsmear
Knee chest= rectum & anus
LOWER EXTREMITIES
_ INSPECT
-skin color, condition, lesions, hair distribution, venous
distention, symmetry and contour, toe nails
PALPATE
-thighs down to feet
-temp, texture,moisture, tenderness
-posterior tibial & dorsalis pedis pulses bilaterall
-capillary on both feet
