The Head-to-Toe Assessment Nursing 101 cheat sheet provides a systematic guide for performing a full physical exam, covering key areas such as neurological, cardiovascular, respiratory, GI, and musculoskeletal systems. It's a quick reference to ensure thorough, accurate patient assessments.
, HEAD-TO-TOE ASSESSMENT
Newborn, Pediatric, and Adult Normals
Newborn Pediatric Adult
Central Nervous System
• Fontanelles soft, not • Behaviour is appropriate for age • Awake, alert, oriented to person,
depressed or bulging and development place, and time
• Normal newborn reflexes, • Awake, alert and oriented to • Follows commands, clear speech,
normal cry person, place and time bilateral hand grasp equal
Infant is alert when awake • GCS normal • Able to verbalize understanding
• Absence of seizure like activity • Fontanelles normotensivebat rest of current health state
• No jitteriness, normal tone and upright • Maintains eye contact
• Communicates thought
processes
• Behaviour appropriate for age
and development
• Regular heart rate 80-160 bpm • Heart rate within normal range: • Regular apical rate between
• BP mean > or = 36 mmHg 1mo-1yr 90-160 bpm 60-100 bpm
• Oxygen saturation > or = 92% 1-5yr 80-140 bpm • Skin warm and dry
• Colour appropriate for 6-10yr 60-110 bpm • Colour normal (no pallor, mottling,
gestational age 10+yr 60-100 bpm dusky, cyanotic)
Cardiovascular
• Central capillary refill <3 secs • Regular pulse • Mucous membranes are pink
• No murmur • No murmur or abnormal heart and moist
sounds • Capillary refill within 3 secs
• Capillary refill < 2 secs • Radial, dorsalis pedis, and posterior
• Skin warm and dry, colour within tibial pulse is regular and palpable
normal limits ( no pallor, mottling, equally
dusky,cyanotic) • No calf tenderness, warmth, or
• Blood pressure within normal range: redness
0-1mo SBP>60 • No extremity edema
1mo-1yr SBP>70
1-10yr SBP>70+
10+yr SBP>90
• No abnormal chest sounds • Breathing pattern regular, rate • Respirations regular in rate
• Normal chest shape as expected for age:
Respiratory
(12-20/min), depth and rhythm
• Symmetric chest rise andfall 1mo-1yr 25-45 bpm • Symmetrical movement of chest,
• Airway patent 1-5yr 20-30 bpm absence of retraction in
• Equal and bilateral air entry 6-10yr 16-24 bpm intercostal spaces
• No evidence of increased 10+yr 14-20 bpm • No SOB at rest or on
work of breathing • Depth, rhythm, quality, and
character as expected for age
exertions
30
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