Head to toe assessment of an adult

Section

Details to Include

General Survey

- Appearance: Describe the patient’s general appearance (e.g., hygiene, posture, grooming). - Behavior: Note demeanor, mood, and level of consciousness. - Vital Signs: Include temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation.

Integumentary

- Inspection: Describe skin color, texture, moisture, and any lesions, scars, or rashes. - Palpation: Note skin temperature, turgor, and edema (if present).

HEENT

- Head: Describe scalp, hair, and any abnormalities (e.g., lumps, tenderness). - Eyes: Note symmetry, conjunctiva, sclera, visual acuity, and pupil response (PERRLA). - Ears: Assess external ears, hearing, and any discharge. - Nose: Inspect nasal mucosa, septum, and patency of nostrils. - Throat: Examine oral mucosa, teeth, gums, and throat for abnormalities.

Neck

- Inspection: Assess for symmetry, swelling, or masses. - Palpation: Check for thyroid enlargement or tenderness. - Range of Motion (ROM): Evaluate neck mobility.

Lymph Nodes

- Palpation: Note size, tenderness, and mobility of cervical, axillary, and inguinal lymph nodes.

Thorax and Lungs

- Inspection: Observe chest symmetry, shape, and effort of breathing. - Auscultation: Document breath sounds (e.g., clear, wheezes, crackles).

Cardiovascular

- Inspection: Note any visible pulsations or jugular vein distention (JVD). - Palpation: Assess peripheral pulses (radial, brachial, dorsalis pedis, posterior tibial). - Auscultation: Listen to heart sounds (S1, S2, murmurs).

Abdomen

- Inspection: Observe shape, contour, and skin condition. - Auscultation: Note bowel sounds in all four quadrants. - Palpation: Describe any tenderness, masses, or organomegaly.

Genitourinary

- Inspection and Palpation: Note bladder distension, tenderness, or abnormalities. - Subjective Data: Include patient-reported urinary frequency, urgency, or incontinence.

Extremities & Peripheral Vascular

- Inspection: Evaluate for symmetry, swelling, or deformities. - Palpation: Assess temperature, capillary refill, and pulses. - ROM and Strength: Test joint range of motion and muscle strength.

Neurological

- Mental Status: Assess level of consciousness, orientation (person, place, time), and cognition. - Cranial Nerves: Evaluate cranial nerve function as applicable. - Motor Function: Test strength, tone, and coordination. - Sensory Function: Check for sensation to touch, pain, or temperature. - Reflexes: Document deep tendon reflexes.