NSG 121 Head to Toe Assessment
Gather appropriate supplies for assessment and any skills
Perform hand hygiene
Preparation Introduce self and Provide privacy
Identify patient with two identifiers
Explain procedure to patient
Determine reason for seeking care
Asks two pertinent questions related to reason for seeking care (When did your
headache start? Are you taking any over the counter medication for it?)
Asks for any allergies
Asks for past medical history
Asks about any previous surgeries
Health History
Asks about family medical history
Collects current medication
list
Conducts assessment for health risk variables (alcohol, drug, and tobacco use)
Provides appropriate health maintenance or education interventions (flu vaccine,
smoking cessation) - Ensure that you take sufficient night rest, and make sure you stay
hydrated throughout the day. Ensure you are up to date with your vaccination.
1. Blood pressure - 119/80
2. Heart Rate - 90 bpm
3.Respiratory Rate - 18 bpm
4. Pulse Oximetry - 95
5. Temperature - 97.0
6. Pain (OPQRST) Onset, Provokes or Palliates, Quality, Radiates, Severity,
Baseline vital signs
Time. O: when did the pain start?
P: Does anything increase or release the pain?
Q: could you describe your pain?
R: Does the pain radiate to other areas?
S: could you rate the pain for me on the scale of 0-10, 0 means no pain, 10 severe
pain T: Is the pain the same intensity as when it started or has it decreased or
increased?
Gather appropriate supplies for assessment and any skills
Perform hand hygiene
Preparation Introduce self and Provide privacy
Identify patient with two identifiers
Explain procedure to patient
Determine reason for seeking care
Asks two pertinent questions related to reason for seeking care (When did your
headache start? Are you taking any over the counter medication for it?)
Asks for any allergies
Asks for past medical history
Asks about any previous surgeries
Health History
Asks about family medical history
Collects current medication
list
Conducts assessment for health risk variables (alcohol, drug, and tobacco use)
Provides appropriate health maintenance or education interventions (flu vaccine,
smoking cessation) - Ensure that you take sufficient night rest, and make sure you stay
hydrated throughout the day. Ensure you are up to date with your vaccination.
1. Blood pressure - 119/80
2. Heart Rate - 90 bpm
3.Respiratory Rate - 18 bpm
4. Pulse Oximetry - 95
5. Temperature - 97.0
6. Pain (OPQRST) Onset, Provokes or Palliates, Quality, Radiates, Severity,
Baseline vital signs
Time. O: when did the pain start?
P: Does anything increase or release the pain?
Q: could you describe your pain?
R: Does the pain radiate to other areas?
S: could you rate the pain for me on the scale of 0-10, 0 means no pain, 10 severe
pain T: Is the pain the same intensity as when it started or has it decreased or
increased?
