Head to Toe Assessment
	1. Visual check of room upon entry for Safety (i.e. call bell within reach, bed low in low position, side rails X 2).

2. Identify the patient. Make sure she or he has an ID band.

3. Neuro—talk to patient assessing orientation(A&Ox3). Perform a more in-depth neuro exam if needed--per patient, history, and hospital documentation. a) Grips and pushes check pedal pulse at that time—(marker: 2nd toe—midfoot) Check for warmth and skin integrity. b) View pupils if necessary (doesn’t hurt—good practice

4. Heart – 5th intercostal space/midclavicular line. Assess: a. Rate (15 sec.),b. Rhythm (regular or irregular), c. Extra sounds (i.e. murmurs)

5. Lungs –This area should be the PRIORITY assessment area. Turn pt. on each side or sit up. a) Begin with POSTERIOR lung sounds, b)Auscultate from BASE to upper for maximum learning and prevents patient tiring. Have patient take deep breaths through MOUTH for maximum expansion. c) Anterior lung sounds-- brief (unless upper airway disease). *Note: Assess back side (integumentary) when pt. turning side to side. Also take note of any dressings while performing other assessments: Location? Dry? Intact?

6. Abdomen—Auscultate x 4 quadrants. Also ask patient when LAST BM? Passing flatus? Voiding?

7. Vital Signs (at beginning of the shift and per floor policy). Assess PAIN level. Remember, pain is considered the fifth vital sign.

8. After completing Head to Toe---CHECK ALL EQUIPMENT. This includes but is not limited to… a. IV pump and fluids (including IV rate) b. Foley (or other catheter) c. O2 d. SCD’s/TEDs e. suction f. Presence of PCA pump g. Drains h. Type of bed i. Tube feeds/TPN.

9. Clean bedside table and surrounding area if needed—and if patient wants you to. Assist with eyeglasses or dentures if needed.

10. Visually check of room for safety concerns such as obstacles, fall hazards, spills