Basic Head-to-Toe Assessment
History of present illness – Brief synopsis of illness from admission to day of
care; include treatment and patient responses/condition.
Vital signs: -Temp, pulse, RR, BP, O2 sat, Ht/Wt (can also be listed in
appropriate system)
Neurological: -Appropriateness of response, speech, affect
-Visual acuity
-Pupils (PERRLA)
-Gait, handgrips, moves all extremities equally
-Neuro deficits (facial drooping, etc)
Pain: location, rating (0-10), FACES pain rating scale
Cardiovascular: -Apical pulse (auscultate for S1 and S2, rate and rhythm in
all areas)
-Telemetry (rhythm)
-Peripheral pulses bilaterally (strength and equality)
-Calf tenderness
-Edema (location/pitting or non-pitting)
-Capillary refill
-IV site, fluid (type, rate), condition
Respiratory: -Observe respiratory rate/rhythm/depth
-Auscultate anterior & posterior lung sounds
-Cough: productive/non-productive
Supplemental oxygen, O2 saturation
Gastrointestinal: -Mouth: condition of teeth, moisture and color of mucous
membranes, dentures, swallowing
-Abdomen: inspect shape, auscultate bowel sounds,
palpate and assess for distension, tenderness, masses
-Last BM (date, quantity, color, consistency)
-Diet/NPO
-NG tube/feeding tube
Genitourinary: -Urine output, color, burning
-Voids, Foley, incontinent, dialysis
-Observe and palpate for distended bladder
-Ask about penile or vaginal drainage, sexual concerns.
-LMP (women of childbearing age)
Musculoskeletal: -Range of motion, muscle strength
Integument: -Skin color, turgor, temperature, moisture, lesions
Psychosocial: -Cultural, social, spiritual supports and concerns
Equipment: -Special equipment used for care (traction, SCD, TED, IS,
etc) can also be listed in appropriate system