HeadtoToeAssessment

V/S
BP/HR/Resp/Temp/Ht/Wt
Neuro
Arouses(easily,mild,moderate,aggressive)stimuli.AAOx(awake,alert,orientedto
person,place,time)PERRLA(pupilsequalroundreactivetolightandaccommodation),
habdgraspequal,unequalstrong,weak,flaccid)MAEWmovesallextremitieswell
.activitylevel/activitytolerance.gaitsteady/unsteady.

Skin
Color,tugor,temp,dry,moist.Mucousmembranedry,moist,pale,cyanotic.Capillaryrefill
(<3secs).Describeandmeasureanyskinlesionsorbreaksinskinintegrity.Describeany
dressingsthatmaybepresent.

Cardiac
S1S2present(rhythm,reg/irreg).peripheralpulse(whichones).Edema(location1+2+ect)
IVsite(redness,swelling,drainage).Fluidsinfusing.

Lungs
Lungsounds,BBS(bilateralbreathsounds)clear,rales,ronchi,wheezing.
LUL,LLL,RUL,RLL,,breathingpattern(labored/unlabored)coughproductive/nonproductive/
describesputum).Oxygenandhowsupplied,o2sat.breathingtx,chesttube(describedsg,
site,drainageandamount)Trachsite(describeskin).Suctioning(oral,nasal,trach)
Describesecretions.

GI
Abd(flat,round,distended,firm)BSpresentx4quad(hypo/hyperactive)dateoflastBM,
Nutritionalstatus(NPO,DAT,tubefeeding).Describeanytubes(NG,G,Jdescribe
dressings/skinsitearoundtubes)Intake/output.

GU
Methodofelimination(foley,voiding,incontinent,suprapubic.)urinecolor,odor,amount.

Pain
Rateonascaleof110,locationofpain,type(dull,ache,radiating),what
increases/decreasespain.documenteffectivenessofmedication.

remembersubjectivecomments.