Head-to-Toe Assessment

Comprehensive system-by-system shift documentation.

For educational use only. Always verify with clinical judgment and facility protocols.

Head-to-Toe Assessment

Comprehensive system-by-system shift documentation.

General / Vital Signs

Level of Consciousness

General Appearance

Vital Signs

HEENT

Head

Eyes

Ears / Nose

Oral / Throat

Neck

Neurological

Orientation

Speech

Motor Strength - Upper

Motor Strength - Lower

Sensation

Cranial Nerves

Cardiovascular

Heart Sounds

Peripheral Pulses

Edema

Capillary Refill

Telemetry

Respiratory

Breath Sounds

Effort

O2 Delivery

O2 Rate / FiO2

Cough

Chest Tubes

Gastrointestinal

Abdomen

Bowel Sounds

Nausea / Vomiting

Diet / PO Intake

Last BM

GI Drains

Genitourinary

Voiding

Output Method

Urine Output Trend

Musculoskeletal

Mobility

Range of Motion

Fall Risk

DVT Prophylaxis

Skin / Integumentary

Color / Temperature

Integrity

Pressure Injury Risk

IV Sites

Wound / Dressing Notes

Pain Assessment

Pain Score

Pain Location

Pain Quality

Non-Pharmacologic Measures

Pain Management Effective

Psychosocial / Safety

Mood / Affect

Restraints

Isolation

Lines, Drains & Devices

IV Access

Drains

Airway Devices

Other Devices

Live Preview

HEAD-TO-TOE ASSESSMENT GENERAL: Patient alert and oriented x4. well-appearing, no acute distress. HEENT: Head normocephalic, atraumatic. Eyes PERRLA, sclera white. no drainage noted. Oral: mucous membranes moist and pink. Neck supple, no JVD. NEUROLOGICAL: oriented x4 (person, place, time, event). Speech clear and coherent. UE motor strength strong and equal bilaterally (5/5). LE motor strength strong and equal bilaterally (5/5). Sensation intact to light touch bilaterally. Cranial nerves intact (facial symmetry, gag reflex present). CARDIOVASCULAR: Heart sounds S1 S2 regular rate and rhythm. Peripheral pulses strong and palpable bilaterally. Edema: none noted. Cap refill brisk, < 2 seconds. Telemetry: N/A (not on monitor). RESPIRATORY: Breath sounds clear to auscultation bilaterally. even and unlabored. On room air. GASTROINTESTINAL: Abdomen soft, non-tender, non-distended. Bowel sounds active in all 4 quadrants. Nausea/vomiting: none. Diet: regular diet, tolerating well. Last BM: today. GENITOURINARY: voiding clear yellow urine. voiding independently. UOP trend: adequate (> 0.5 mL/kg/hr). MUSCULOSKELETAL: ambulatory independently. ROM: full ROM all extremities. Fall risk: low risk. DVT prophylaxis: SCDs applied and functioning. SKIN/INTEGUMENTARY: warm, dry, and appropriate color. Integrity: intact throughout. Pressure injury risk: low risk (Braden 19+). IV sites: patent, no signs of infiltration. PAIN: 0/10 (no pain). PSYCHOSOCIAL: Mood/affect: appropriate and cooperative. SAFETY: call light in reach, bed in low position, 2 side rails up, non-skid footwear provided.

Tip: Customize the template using the options on the left. The signature [NursingWorksheets.com] is added automatically when you copy.