Head to Toe Patient Assessment - Stanbridge University
[Pages:2]POLST/Code Status
GENERAL SURVEY
How does the client look?
NEUROLOGICAL
(LOC) Level of Consciousness Eyes Pupils Ears Extremities Cranial Nerves - intact Pain
Head to Toe Physical Assessment
VS 7:30 Temperature
Pulse
Respirations
BP
/
VS 11:30 Temperature
Pulse
Respirations
BP
/
Pain /10 Pain /10
Age___________
Male/Female Body Build: Thin Cachectic Obese WNL
Height___________ Weight____________
Well groomed Poorly Groomed
Facial Expression: Anxious Happy Sad Angry
Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate
Oriented x 4: Person Place Time Event Response to touch/voice
Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/
Blind
Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual
Pupil size before light ______mm Pupil size after light ______mm
Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen Drainage
Hand grips +1 +2 +3 +4 +5 equal unequal
Foot pushes +1 +2 +3 +4 +5 equal unequal
I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral)
VII (facial movement/taste)
VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue movement)
Character Onset Location Duration Severity Pattern Associated Factors COLDSPA
CARDIOVASCULAR
Skin / Mucous Membranes Radial and Pedal Pulses Apical Radial Pulses Carotid Pulses Capillary Refill Jugular Neck Veins Edema Calf Tenderness Heart Rhythm/ Sounds ? S1S2
IV
RESPIRATORY
Respirations
Lung Sounds
Cough Oxygen
Respiratory Treatments
ALLERGIES
Pink
Pale
Cyanotic
Jaundiced
Ruddy
Flushed
Diaphoretic
Radial: Palpable (L/R)
Absent (L/R)
Pedal: (DP PT)
Palpable (L/R) Absent (L/R)
(2 people simultaneously)
Apical and Radial
Pulse Deficit
(DO NOT TAKE AT SAME TIME) Right
Left
Thrill
Bruit
Normal ( ................
................
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