Head to Toe Assessment Charting

Hello future nurses! Finals are just around the corner for me and I hope all of you are feeling confident in your material and test taking strategies!

My clinical this semester was all about head to toe patient assessment and charting. ALWAYS CHART OR IT NEVER HAPPENED. Be as detailed as possible because you never want there to be room for misinterpretation.

I was given a few different documents designed for charting while assessing your patient and found one particularly helpful. I created something similar and hope it will help you all in your head to toe assessments.

Keep on studying for those finals! You can do it!

Student Nurse

Patient name and DOB

PAIN Assessment: Patient denies pain

Pain scale 0-10 Location Duration

Radiation Aggravation Alleviation

Presentation: Alert Confused Anxious Agitated

Decreased Level of Consciousness

Orientation: Person Place Time Situation

V/S: Temp BP P HR

Pupils: PERRLA Fixed Pinpoint Dilated Unequal

Face/Lips: Pink Tan Pale Jaundice Cyanotic Mottled

Normal Skin Tone per PT

Symmetrical Asymmetrical

Tongue Extension: Midline Deviated Left Deviated Right

Lungs:

Breath sounds in LUL LLL RUL RML RLL

Clear

Rhonchi

Wheezes

Crackles

Respiratory Pattern: Symmetrical Asymmetrical Unlabored Labored Accessory muscles Non-productive cough Productive cough

Heart S1 & S2: Present Murmur Gallop (S3/S4) Regular Irregular

Abdomen: Flat Obese Rounded Soft Firm Distended

Tender Non-tender

Bowel sounds: RLQ RUQ LUQ RLQ

Active

Hypoactive

Hyperactive

Absent

Skin: Intact No breakdown noticed Ecchymosis Abrasion

Pressure Ulcer Rash

If abnormalities are present, describe…

Extremities:

Color: Tan Pink Pale Cyanotic Jaundice

Mottled Normal skin color per patient

Strength: Hand grasp Ankle flexion Ankle extension

Key: W=Weak S=Strong F=flaccid Sp=Spasticity

Strength equal bilaterally: Hand grasp Ankle flexion Ankle extension

Key: S=Symmetrical A=Asymmetrical L=Left weaker than Right R= Right weaker

than Left

Pulses: Radial Pedal Posterior Tibial

Pulse Key: E=Equal symmetrically U=Unequal

Pulse Grade: Radial Pedal Posterior Tibial

Grade Key: 0 to 4 +:

0 indicating no palpable

1 + indicating a faint, but detectable

2 + suggesting a slightly more diminished pulse than normal

3 + is a normal pulse

4 + indicating a bounding pulse.

Edema: Present Location No Edema Present Pitting

Non-pitting

Capillary Refill: Less than 3 seconds Greater than 3 seconds

Assessment Comments: