Complete Head to Toe Assessment

Here's a quick reference table to try to help understand what should be assessed under each body system.


This isn't an end all be all list. There's a lot of things that could be added or deleted. Different units will be focused more on certain things than others. That's fine. I've been working on an ICU lately, so there are some things on here that would most likely only show up on one of those units such as ventilator settings. 

System	Usual Assessment	Additional Assessments
Neuro	Level of consciousness, orientation, motor ability, strength, ROM, speech, pupillary reaction to light, color and condition of the sclerea, temporal pulses, headache, vision, hearing, paresthesias, reflexes, intensity and perception to pain	Restraints, cervical collar, traction, surgical dressing, ICP monitoring device, level of sedation, PCA device
Cardio	Pulses, capillary refill, edema, heart sounds, murmurs, thrills, neck veins, PMI, ECG, arrhythmias, chest pain, activity tolerance	vascular access, cardiac output, pressure monitoring, pacemaker, compression stockings/device
Resp	Pulse oximeter, depth, rate, rhythm, use of accessory muscles, cyanosis, sputum- color/amount, cough, wheezes, stridor, position of trachea, suctioning tolerance	Supplemental O2, artificial airway size/position, mechanical ventilator settings, pleural chest tube, apnea monitor
GI/GU and Renal	Abdominal pain/ tenderness, guarding, distention, tolerance to eating/feeding, nutritional status, character of vomit/stool, nausea/vomiting, bowel sounds, urine amount/quality, foley status	Feeding tube type/ size/ location, feeding formula/rate, GI tubes patency/ drainage, surgical dressings
Skin	Color, texture, turgor, temperature, rashes, abrasions, wounds, burns, bruises, inflammations, itching, burning	Type of bed, patient's tolerance of bed, decubitus dressing, protective aids
Extremities	Limitations in movement, deformities, contractures, signs of ischemia: pain, pallor, paresthesia, paralysis, pulselessness, cold	Traction: weight, status, alignment, patient tolerance, pin site. Casts, splints, restraints, compression device
Psych	Emotional state, support systems, communication, coping ability, sleep/rest status	Patient/family teaching needs, social service needs, transfer/discharge planning

I hope this helps! Let me know if you have any questions in the comment section below, or shoot me an email. 

Xoxo,

Nightingale