Manual of Policies and Procedures for Wade Nursing Registry

Guideline for Head to Toe Observation

When you assess your client for either a daily observation of for a possible problem or concern, consider the following while looking at your client.

  1. Consciousness
    Alert
    Confused
    Slow to react
    Confused
    Drowsy
    Listless

  2. Grooming
    Clean
    Untidy
    Dirty

  3. Skin
    Pale
    Clammy
    Rough
    Bruises
    Open sores
    Yellow
    Dry
    Red
    Rashes
    Scaly patches

  4. Mood
    Cheerful
    Anxious
    Hostile
    Agitated
    Angry
    Withdrawn
    Sullen
    Demanding
    Irritable
    Sad

  5. Hair and Scalp
    Clean
    Oily
    Dirty
    Sores
    Matted
    Dandruff
    Dry

  6. Eyes
    Bright
    Sensitive to light
    Dull
    Discharge
    Blind
    Red
    Sees well
    Glassy
    Sees poorly

  7. Ears
    Discharge
    Hears well
    Deaf
    Pain
    Difficulty hearing

  8. Nose
    Dry
    Bleeding
    Discharge
    Stopped up, congested

  9. Mouth
    Odor
    Discharge
    Difficulty chewing
    Difficulty swallowing
    Gums, red, bleeding
    Bluish or pale lips
    Sores
    Condition of teeth and dentures

  10. Speech
    Normal
    Slurred
    Unable to speak
    Individual
    Difficult talking

  11. Breath
    Slow
    Coughing
    Rapid
    Noisy
    Painful
    Difficult breathing

  12. Neck
    Swelling
    Pain
    Difficult swallowing

  13. Arms, Wrists, Hands, and Fingers
    Bruises
    Rashes
    Cold
    Cuts
    Swelling
    Pale or bluish fingernails

  14. Movement
    Easy
    Painful
    Twitching
    Difficult
    Shaking
    No movement - one side or both sides

  15. Strength
    Weakness - general or one sided
    Difficult holding objects
    Loss of strength

  16. Feeling
    Numbness
    Pain
    Tingling sensation

  17. Chest and Abdomen
    Bruises
    Rashes
    Pain
    Cuts
    Swelling

  18. Breasts
    Lumps
    Soreness
    Irritation of skin under the breast
    Discharge from nipple
    Pain

  19. Pubic Area
    Bruises
    Rashes
    Pain
    Cuts
    Swelling
    Lumps
    Discharge
    Bleeding

  20. Legs, Ankles, Feet, and Toes
    Bruises
    Rashes
    Pain
    Sores or discoloration of the area

  21. Movement
    Easy
    Painful
    Twitching
    Difficult moving or applying pressure
    Shaking
    No movement
    Change in strength
    Numbness or tingling

  22. Upper and Lower Back and Buttocks
    Bruises
    Scaly patches
    Redness
    Swelling
    Sores
    Dry skin
    Pain

  23. Activities of Daily Living
    Performs ADL without assistance
    With assistance
    Can not perform
    Personal care (bathing, hair care, dressing, brushing teeth, shaving)
    Toilet (toilet, commode, urinal, bedpan)
    Eating (in bed, in room, at table)
    Moving (standing, sitting, walking)

  24. Appetite
    Fluids
    Foods
    Eats
    Thirsty
    Drinks
    Poor

  25. Elimination
    1. Urine
      Pale or red
      Odor
      Large amounts
      Difficulty urinating
      Incontinence
      Dark amber
      Small amount
      Painful urination
      Frequent urination

    2. Feces (bowel movement)
      Black, tarry
      Clay color
      Diarrhea
      Difficult moving bowels
      Painful movements
      Frequent movement
      Incontinence
      Bloody
      Watery
      Odor (foul)

  26. Equipment needed by the Client
    Wheelchair
    Oxygen
    Commode
    Hospital bed
    Walker
    Catheter
    Cane

  27. Pain
    Dull
    Stabbing
    Severe
    Location
    Aching
    Pain that comes and goes