![]() ![]() Auscultate with both the bell and the diaphragm of the stethoscope over the five auscultation areas of the heart.Palate the nail beds for capillary refill.Note the presence and amplitude of pulses. Palpate and compare the radial, brachial, dorsalis pedis, and posterior tibial pulses bilaterally.The lower extremities for hair distribution, edema, and signs of deep vein thrombosis (DVT).The bilateral upper and lower extremities for color, warmth, and sensation.The neck for JVD in upright position or with head of bed at 30-45-degree angle.The face, lips, and extremities for pallor or cyanosis.Be aware of previously diagnosed cardiovascular conditions and currently prescribed medications and how these impact your assessment findings. Ask if they are having chest pain, shortness of breath, edema, palpitations, calf pain, or pain in their feet or lower legs when exercising. Perform a cardiovascular system assessment:.Palpate the lymph nodes (per agency policy).Ask the patient to swallow their saliva and note any difficulty swallowing. Inspect the oral cavity for lesions, tongue position, moisture, and oral health. Inspect the external eye and the external ear.Ask if they have trouble hearing or experience ringing in their ears.Ask if they have any difficulty seeing or blurred vision.Ask if they use glasses, hearing aids, or dentures.Ask if they are having any problems with their teeth or gums, and if this has impacted their ability to eat.Be aware of previously diagnosed head, neck, eye, or ear conditions and associated medications and how these impact your assessment findings. Perform a basic head, neck, eye, and ear assessment:.Perform a focused assessment if neurological or musculoskeletal condition is present.Assess fall assessment risk per agency policy.Note unanticipated neurological findings in symmetrical facial expressions, extremity movement, and speech and obtain emergency assistance as needed.Assess level of consciousness and orientation to person, place, and time.Be aware of previously diagnosed neuromuscular conditions and currently prescribed medications and how these impact your assessment findings. Inquire if the patient has experienced loss of balance, decreased coordination, previous falls, or difficulty swallowing. Ask if headache, dizziness, weakness, numbness, tingling, or tremors are present. If pain or discomfort is present, perform comprehensive pain assessment using PQRSTU. Evaluate for the presence of pain or other type of discomfort.(Initiate emergency assistance as needed.) Ask, “Do you have any concerns or questions you’d like to talk about before we begin?” Evaluate chief concern using PQRSTU (i.e., ask the patient their reason for seeking/receiving care).Address patient needs before starting assessment (toileting, glasses, hearing aids, etc.).Include general appearance, behavior, mood, mobility (i.e., balance and coordination), communication, overall nutritional status, and overall fluid status. Perform a general survey while completing the head-to-toe assessment.Mental Status: Is the patient responsive and alert?.Circulation: Are there any abnormal findings in the overall color and moisture of the patient’s skin (cyanosis, diaphoresis)?.Breathing: Is the patient breathing normally?.Airway: Is the airway open? Is suctioning needed?.Perform a primary survey to ensure medical stability. ![]() Identify the patient using two patient identifiers (e.g., name and date of birth).Ensure the patient’s privacy and dignity.Use appropriate listening and questioning skills.Explain the process to the patient and ask if they have any questions.Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.Check the room for transmission-based precautions.Perform hand hygiene before providing care and clean stethoscope.Gather supplies: stethoscope, penlight, watch with second hand, gloves, hand sanitizer, and wound measurement tool.Unanticipated findings should be reported per agency protocol with emergency assistance obtained as indicated. Focused assessments should be performed for abnormal findings and according to specialty unit guidelines. Assessment techniques should be modified according to life span considerations. Students should use a systematic approach and include these components in their assessment and documentation. This checklist is intended as a guide for a routine, general, daily assessment performed by an entry-level nurse during inpatient care. Appendix C – Head-to-Toe Assessment Checklist Head-to-Toe Assessment Checklist ![]()
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