Head to Toe Check Off

Question 1

Normal Vitals

Answer 1

BP: 120/80 mmHg
HR: 60-100 bpm
Resp Rate: 12-20 breaths/min
Pulse: 2+ strength
SpO2: >92% RA
Temp: 36.2 C - 37.2 C (97.2 F - 99.9 F)
Cap refill = <2 seconds

Question 2

Pulse Quality Scale

Answer 2

0 - absent
1+ - diminished, weak
2+ - expected. Strong, palpable
3+ - bounding. Really strong.
4+ - really strong, persists even with pressure

Question 3

Tonsils Scale

Answer 3

0 - absent. The tonsils have been removed
1+ - tonsils are visible. This is the expected finding
2+ - tonsils are more visible than usual. Could be a little swollen
3+ - tonsils are really swollen and red.
4+ - tonsils are near occluding the back of the throat. Worry about airway at this point.

Question 4

Reflexes & Strength Scale

Answer 4

0 - absent reflexes / no strength
1+ - reflexes/ strength present but diminished
2+ - expected. Reflexes & strength are present and the regular amount
3+ - bounding. A little hyperactive/strong
4+ - really strong reflexes or strength grips

Question 5

Edema Scale

Answer 5

0 - no edema
1+ - mild pitting edema. Depression disappears within 10-15 seconds.
2+ - Moderate pitting edema. Depression disappears within a minute.
3+ - Moderately severe pitting edema. Depression may last more than a minute.
4+ - Severe pitting edema. Depression lasts more than 2 minutes.

Question 6

General

Answer 6

Subjective:
1. Standard protocol: Name, DOB, allergies, CC. You can get to CC in the rest of the assessment - don’t have to do it right away.
2. Medications.
3. Social habits (ETOH, drugs, sexual history, environmental exposures)
4. Assess if there is any pain. OLDCARTS
5. Any falls or injuries in the last year?

Objective:
1. Assess for lines, drains, or tubes
2. LOC (A&O x4?) - can you tell me where we are, what your name is, what date it is, and if they say their CC then they know why they’re there

Question 7

HEENT

Answer 7

Subjective:
1. Personal or familial h/o HEENT diagnosis or procedures.
- vision changes or surgeries, ear infections, tonsil removals
2. Ask about personal visual/audio deficits.
3. Ask about changes in ability to taste / smell.

Objective:
1. Inspect head/face shape and symmetry
- Ask patient to smile!
2. Inspect skin and hair of the head and neck
- Even distribution, texture, oil/dry
3. Assess PERLA & pupil size (based on penlight… 0-5)
- Shine the pen light in the pupils. Ask pt to follow your finger in and out and side to side.
4. Assess ears, nose, mouth, and throat with the otoscope (basically just inspection + tongue depressor for throat).
5. Assess ability to swallow and tracheal alignment.
6. Palpate lymph nodes of the throat and neck.
- Should be barely felt, not swollen. No goiters in the thyroid.

Question 8

Neurologic/Musculoskeletal

Answer 8

Subjective:
1. Ask about changes in strength or ROM in upper extremities.
2. Ask about numbness, tingling, or loss of sensation (specifically in the upper extremities, but also lower is applicable).

Objective:
1. Assess skin of upper extremities
4. Assess grip/push/pull

Question 9

Respiratory/Cardiovascular

Answer 9

Subjective:
1. Personal or familial h/o respiratory related dx or procedures.
2. Ask about SOB or dyspnea.
3. Personal or familial h/o cardiac related dx or procedures.
4. Ask about chest pain/pressure/palpitations.

Objective:
1. Assess for edema in the upper extremities
2. Assess radial pulses bilaterally
3. Assess capillary refill bilaterally
4. Assess for signs of labored breathing
5. Assess skin of the chest and back while you listen to lungs and heart sounds
6. Compare apical and radial pulses

Question 10

Abdominal

Answer 10

Subjective:
1. Personal or familial h/o abdominal related dx or procedures.
2. Ask about abdominal pain, discomfort, and N/V.
3. Ask about changes in bowel habits.
4. Ask about pain, changes, or difficulty in urinary patterns.

Objective:
1. Inspect abdomen shape/symmetry.
2. Inspect for lumps, bruises, pulsations, and skin integrity.
3. Auscultate the 4 quadrants
4. Palpate the 4 quadrants

Question 11

Lower body

Answer 11

Subjective:
1. Ask about changes in strength or ROM of the lower extremities.

Objective:
1. Assess skin of lower extremities
2. Check for edema of lower extremities BILATERALLY (0-4+)
3. Assess pedal pulses bilaterally (0-4+)
4. Assess push/pull/lift of the lower extremities bilaterally (0-4)
5. Assess capillary refill of the toes bilaterally

**Ask if there are any additional concerns before you leave and wrap up the assessment!