1. Performing a Head to Toe
Assessment
Performance Behaviors

2. Assess level of consciousness and
orientation
• Person
• Place
• Time

3. Assess and Compare Bilateral Upper
Extremities
• Hand grasps for equality and strength
• Temperature and color
• Radial pulses
• Capillary refill
• Sensation

4. Assess Apical Pulse
• Auscultate heart sounds at point of maximal
impulse (PMI).
• Listen for one minute, noting rate and regularity.
• http://www.practicalclinicalskills.com/auscultatio
n-lesson-
description.aspx?coursecaseorder=1&courseid=2
2

5. Heart Sounds

6. Assess Lungs
• Listen and observe rise and fall of chest and
count respirations
• Auscultate breath sounds
Assess anterior chest in 4 sites and 2 lateral sites
Assess posterior chest in 4 sites and 2 lateral sites

7. Lung Sounds