HEAD-TO-TOE ASSESSMENT

Patient: [Name]
Date of birth: [Date]
Unit and room: [Location]
Date and time: [Date, time]
Reason for admission: [Diagnosis or procedure, and day of stay or post-op day]
Allergies: [Drug, latex, and food allergies, with reactions]
Code status: [Code status]
Nurse: [Name, credentials]

VITAL SIGNS AND PAIN
Vital signs: [Temperature, HR, BP, RR, SpO2, and oxygen device and flow]
Early warning score: [Score and tool, if your unit uses one]
Pain: [Site, score and scale used, character, last dose, and reassessment]

NEURO AND HEENT
Level of consciousness: [Alert, responds to voice, responds to pain, or unresponsive]
Orientation and cognition: [Person, place, and time; delirium screen result; usual baseline]
Pupils: [Size, equality, and reaction to light]
Speech and limbs: [Speech, and strength and sensation in all four limbs]
HEENT: [Glasses or hearing aids, mucous membranes, dentures, swallowing]

CARDIOVASCULAR
Heart: [Apical rate and rhythm, heart sounds, telemetry rhythm if monitored]
Circulation: [Peripheral pulses, capillary refill, skin color and temperature]
Edema: [Site and grade]
VTE prevention: [Compression devices, anticoagulant given, mobility]

RESPIRATORY
Breathing: [Rate, depth, effort, accessory muscle use]
Breath sounds: [By lung field, with any added sounds]
Cough and sputum: [Cough, sputum color and amount]
Oxygen and devices: [Device and flow, incentive spirometer use]

GI AND GU
Abdomen: [Shape, bowel sounds, tenderness, distension]
Intake: [Diet ordered, how much eaten and drunk, nausea or vomiting]
Bowels: [Last bowel movement, flatus]
Urine: [Voiding or catheter, color, output in mL, time of last void]

MUSCULOSKELETAL AND SKIN
Mobility: [Activity ordered, assistance and aids, weakness, range of motion]
Skin: [Color, temperature, moisture, turgor]
Wounds and incisions: [Site, appearance, drainage, dressing]
Pressure injury risk: [Braden score, pressure points checked, repositioning]

PSYCHOSOCIAL AND SAFETY
Mood and coping: [Mood, anxiety, sleep, support present]
Communication: [Language, interpreter, hearing or vision needs, teaching given]
Fall risk: [Score and tool, precautions in place]
Safety measures: [Bed low, call bell in reach, isolation, restraints if any]

LINES AND DRAINS
IV access: [Type, site, gauge, insertion date, site condition, infusions]
Drains and tubes: [Type, site, output, and appearance]
Urinary catheter: [Type, insertion date, ongoing need, or none]

PLAN AND ESCALATION
Changes since last assessment: [New or abnormal findings]
Escalated to: [Name and role, time, what was reported, and the response or orders]
Nursing plan: [Interventions, teaching, and next reassessment time]

Signed: [Nurse name, credentials, date and time]