Intensive Care Head to Toe Assessment: A Comprehensive Checklist

When a patient is admitted to the intensive care unit, it is vital that a comprehensive assessment is conducted in order to determine the best course of treatment. This head-to-toe assessment should include an evaluation of all body systems, as well as any acute issues or concerns that may be present.

We will discuss the components of a comprehensive ICU head-to-toe assessment.

Table of Contents

Introduce Yourself & Start Your Assessment

The first step in conducting a head-to-toe assessment is to introduce yourself to the patient. This helps to establish rapport and puts the patient at ease. Not all Intensive Care Patients are sedated, but if they are sedated it is still best to speak with your patient as they can still hear you when you are providing care.

Once you have introduced yourself, explain what you will be doing and why it is necessary. For example, you might say something like, “I am going to conduct a head-to-toe assessment. This will help us to determine what is going on with your body and how we can best help you.”

neurological assessment

Neurological Assessment

Level of Consciousness

You will want to begin by assessing your patient’s Level of Consciousness (LOC) using the Glasgow Coma Scale. This will give you a baseline for future comparisons. The following are LOC status options for your ICU patient:

  • Alert: Attentive, awake, and on guard
  • Awake: Not asleep, lucid
  • Lethargic: Severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep
  • Obtunded: Lessened interest in the environment, slowed responses to simulation, and tends to sleep more than normal with drowsiness in between sleep states
  • Stupor: only vigorous and repeated stimuli will arouse the patient. When left undisturbed, the patient will immediately lapse back to the unresponsive state.
  • Comatose: state of unarousable unresponsiveness
  • Confused: Profound deficit that includes disorientation and difficulty following commands
  • Decerebrate: Extension of all four extremities with a rigid posture and no response to painful stimuli
  • Decorticate: Flexion of the upper extremities with the extension of the lower extremities and no response to painful stimuli

Patient Orientation

You will also want to assess the orientation of the patient. The following are the orientation options for your ICU patient:

  • Oriented to Person: Aware of their own name and who they are
  • Orientated to Place: Aware they are in the hospital setting
  • Oriented to Time: Aware of date, month, and/or year. Patients may forget the date because time can be lost while in the hospital.
  • Oriented to Event: Aware of why they are in the hospital
  • Responsive to Touch/Voice: Response to either your voice or stimulation through touch
  • Unresponsive: Unresponsive to any kind of stimuli

Eye/Pupil Assessment

The next step is to assess your patient’s eyes and pupils. You will want to check for the following:

  • Unaided sight: Does not have any deficits or need for sight devices
  • Sight Devices: Glasses, Contact Lenses, Implants
  • Sight Deficits: Blind

Pupil Assessment

  • Equal: pupils should be the same size. If they are not, this may be an indication of a problem such as a stroke, aneurysm, or intracranial hemorrhage to name a few.
  • Round: the pupil should be round, not oval-shaped or irregular in any way
  • Reactive to Light: the pupil should constrict when exposed to light
  • Accommodative: the pupil should change size in response to focusing on near or far objects.
  • Sluggish: the pupil may not react as quickly as usual to light, but should still be reactive (very subjective)
  • Brisk: the pupil should react quickly to light (very subjective)
  • Nonreactive to Light: the pupil does not react at all to light. This can be an indication of a serious problem related to damage to the optic nerve.
  • Consensual: the pupil of the opposite eye should constrict when the examiner shines a light into one eye.
  • Pupil Size: should be approximately 2 to 4 mm in diameter for an adult. If the pupil is larger or smaller than this, it may be an indication of a problem. If the pupils are dilated it may be a sign of an aneurysm. If the pupils are constricted, it may be a sign of a cluster headache. Unequal-sized pupils may be a sign of head trauma. This list is not all-inclusive.

Ears Assessment

The next step is to assess your patient’s ears. You will want to check for the following:

  • Unaided hearing: Does not have any deficits or need for hearing devices
  • Hearing Devices: hearing aids, cochlear implants
  • Hearing Deficits: deaf or hard of hearing

Extremities Assessment

The next step is to assess your patient’s extremities. You will want to check for the following:

  • Hand grips: both hands should have a firm grip and be equal on both sides
  • Foot pushes: both feet should have equal strength with both flexion and extension

Pain Assessment

The final step of the neuro assessment is to assess your patient’s pain. You will want to check for the following:

Conscious ICU Patients

  • Character: describe the pain; throbbing, aching, sharp, dull
  • Location: where is the pain?
  • Onset and Duration: when did the pain start and how long has it been going on?
  • Radiation: does the pain move to another area?
  • Intensity: rate the pain on a scale of 0 to 10
  • Severity: how much does the pain interfere with daily activities?
  • Alleviating and Aggravating Factors: what makes the pain better or worse?

Unconscious ICU Patients – Critical Care Pain Observation Tool (CPOT)

  • Facial Expression: relaxed, neutral (0), tense (1), grimacing (2)
  • Body Movements: absence of movements (0), protection (1), restlessness (2)
  • Muscle Tension: relaxed (0); tense, rigid (1); very tense or rigid (2)
  • Compliance with Ventilation: tolerating ventilator or movement (0); coughing but tolerating (1); fighting ventilator (2)
  • OR Vocalization (extubated patients): talking in normal tone or no sound (0); sighing or moaning (1); crying out or sobbing (2)

Cardiovascular Assessment

Skin/Muscous Membranes

  • Pink: skin should be pink in color and moist
  • Pale: skin may be pale in color. This could be a sign of anemia, shock, or cardiac problems
  • Jaundiced: skin may be yellow in color. This could be a sign of liver damage or problems
  • Cyanotic: skin may be blue in color. This could be a sign of lung problems or carbon monoxide poisoning
  • Ruddy: skin may be red in color, especially on the face like its on fire or blotchy in areas. This could be a sign of anemia, fever, or high blood pressure
  • Flushed: skin may be red in color all over the body including the face. This could be a sign of anemia, fever, or high blood pressure
  • Diaphoretic: skin may be wet or sweaty. This could be a sign of an infection, heat exhaustion, or low blood sugar
  • Dry: skin may be dry and cracked. This could be a sign of dehydration, malnutrition, or diabetes

Radial and Pedal Pulses

Radial and Pedial should be strong, equal on both sides, and regular.

  • Doppler: a machine that helps amplify the sound of pulses that cannot be palpated
  • Absent: could be a sign of hypotension or shock
  • Weak or Thready: could be a sign of anemia, hypotension, or shock
  • Irregular: could be a sign of arrhythmia
  • Bounding: could be a sign of hypertension
  • Full and Rapid: could be a sign of tachycardia

Apical Pulse

The apical pulse is located at the apex of the heart and should be regular. Most accurate when determining heart rate for medications such as digoxin.

Carotid Pulses

The carotid pulses are located on either side of the neck and should be strong, equal on both sides, and regular.

  • Thrill: a vibration that can be palpated over the pulse. This can be a sign of valvular heart disease such as aortic stenosis
  • Bruit: a swishing sound that can be heard with a stethoscope over the pulse. This can be a sign of valvular heart disease such as stenosis or disruption of normal blood flow.

Having a thrill and bruit over an arteriovenous (AV) fistula used for hemodialysis is a normal finding.

Capillary Refill

The capillary refill is the time it takes for blood to return to the area after being pressed. It should be less than 3 seconds. Delayed capillary refill can be a sign of dehydration, shock, or hypothermia.

Jugular Neck Veins

The jugular veins are located on either side of the neck and should be flat or only slightly distended.

  • Elevated or Distension could be a sign of right-sided heart failure

Edema

Edema is the abnormal accumulation of fluid in the tissues. It can be classified as pitting or non-pitting.

  • Pitting edema is when you press your finger into the skin and an indentation remains. This type of edema is usually indicative of venous insufficiency or congestive heart failure.
  • Non-pitting edema is when you press your finger into the skin and no indentation remains. This type of edema can be indicative of lymphedema, myxedema, or cellulitis.

Heart Sounds and Rhythm

Heart sounds should be clear and without murmur. The heart rhythm should be regular.

  • Regular: heart sounds that are consistent in rhythm and without any irregularities
  • Irregular: heart sounds that are inconsistent in rhythm and with irregularities
  • Murmur: an extra heart sound that is caused by turbulent blood flow
  • Extra Sounds: sounds that are caused by something other than the heart such as a pericardial knock or gallop. An S3 heart sound could mean congestive heart failure while an S4 sound (S gallop) could mean severe congestive heart failure.
  • Strong: indicates a forceful heartbeat. It can be easily auscultated with your stethoscope.
  • Faint: indicates a weak heartbeat. It can be difficult to auscultate with your stethoscope.
  • Muffled: heart sounds that are muffled or difficult to hear. This can be caused by excess fluid around the heart such as pericardial effusion, tamponade, or constrictive pericarditis.

Heart rhythms can be classified as sinus, atrial, junctional, or ventricular.

  • Sinus: the heart rate is regular and originates from the sinus node.
  • Junctional: the heart rate is regular and originates from the AV node.
  • Atrial: the heart rate can be regular or irregular and originates from the atria.
  • Ventricular: the heart rate can be regular or irregular and originates from the ventricles.
  • Arrhythmias are abnormalities in heart rhythm. They can be caused by electrolyte imbalances, medications, or underlying heart conditions.

Cardiovascular Devices

Cardiovascular devices such as pacemakers or implantable cardioverter defibrillators (ICDs) can be lifesaving. It is important to know the type of device and when it was placed.

  • Pacemakers: a device that is placed under the skin on the chest and delivers electrical impulses to the heart to maintain a regular heart rhythm.
  • Implantable cardioverter defibrillator (ICD): a device that is placed under the skin on the chest and delivers electrical shocks to the heart to prevent life-threatening arrhythmias.

Respiratory Assessment

Respirations and Rate

  • Regular: even and regular
  • Irregular: uneven and not regular
  • Labored: breathing that is difficult or requires more effort than usual
  • Shallow: breathing that is shallow or does not go deep into the lungs
  • Symmetrical: both sides of the chest rise and fall evenly
  • Asymmetrical: one side of the chest rises more than the other or one side does not rise. This can be a sign of a pneumothorax.
  • Rate: the number of breaths per minute. Normal: 12-20 breaths per minute
  • Tachypnea: more than 20 breaths per minute
  • Bradypnea: less than 12 breaths per minute

Lung Sounds

  • Clear: no abnormal sounds
  • Wheezes: high-pitched, continuous sounds that are caused by obstruction of airflow. They can be heard best on expiration.
  • Rales/Crackles: a coarse, bubbling sound that is caused by fluid in the airways. It can be heard best at the end of inspiration.
  • Stridor: a high-pitched, continuous sound that is caused by obstruction of airflow. It can be heard best on inspiration.
  • Rhonchi: a low-pitched, continuous sound that is caused by obstruction of airflow in the large airways. It can be heard best on expiration.
  • Nasal Flaring: the nostrils open up wider than normal when breathing. This can be a sign of respiratory distress.
  • Sternal Retractions: the skin is pulled in over the sternum when breathing. This can be a sign of respiratory distress, or obstructive diseases such as asthma, or pneumonia.
  • Intercoastal Retractions: the skin is pulled in between the ribs when breathing. This can be a sign of respiratory distress, COPD, or pneumothorax.

Cough Assessment

  • Dry: no mucus or sputum is produced
  • Moist: mucus or sputum is produced
  • Nonproductive: No mucus or sputum is produced
  • Productive: mucus or sputum is produced

Oxygen Delivery Assessment

  • Room Air: no supplemental oxygen is required
  • Nasal Cannula: a small tube that delivers oxygen to the nose. The oxygen flow rate is usually between 2 and 6 liters per minute.
  • Simple Face Mask: a mask that covers the nose and mouth. The oxygen flow rate is usually between 6 and 10 liters per minute.
  • Non-Rebreather: a mask that covers the nose and mouth with a one-way valve. The oxygen flow rate is usually between 10 and 15 liters per minute.
  • CPAP: a mask that covers the nose and mouth with a one-way valve. A small tube delivers oxygen at a constant pressure.
  • BiPAP: a mask that covers the nose and mouth with two one-way valves. A small tube delivers oxygen at two different pressures, one for inspiration and one for expiration.
  • Mechanical Ventilator: a machine that helps a person breathe. A small tube is placed in the mouth or nose and delivers oxygen at a set rate and pressure. It is good to know the settings of the ventilator, such as rate, tidal volume, FiO2, and PEEP.

Gastrointestinal Assessment

Oral Assessment

  • Teeth: are they in good repair? Are there any missing teeth?
  • Dentures: are they in good repair? It is always best to send home dentures with the family if the patient is intubated and not using them. These are expensive.
  • Decay/Caries: any evidence of decay or cavities?
  • Dysphagia: any difficulty swallowing? You will not want to feed a patient or allow water if there is difficulty swallowing present as this material can go into the patient’s lungs causing aspiration and leading to worsening patient conditions.

Abdominal Assessment

  • Soft: able to push down on the abdomen and the overall condition feels soft
  • Round: the abdomen is distended and the patient’s waistline is increased
  • Flat: the abdomen is pulled in and there is no distention
  • Obese: the patient has a BMI of 30 or greater and an overall accumulation of fat around the hips and thighs
  • Firm: unable to push down on the abdomen, feels hard to the touch
  • Distended: the abdomen is larger than normal and is beyond the patient’s waistline normally. Often accompanied by bloating, trapped gas, and digestive contents
  • Tender: pain is elicited when abdominal pressure is applied
  • Non-Tender: no pain is elicited when abdominal pressure is applied

Bowel Sounds

  • Normoactive: present, active, and normal
  • Hypoactive: present but decreased or low in volume. This can indicate constipation.
  • Hyperactive: high in volume, loud, and increased. This can indicate diarrhea.
  • Absent: no bowel sounds are present. This can indicate little or no movement is occurring in the intestines due to various causes. Most of the time your patients will have a nasogastric tube present if there is no movement in the bowels due to an obstruction or ileus.

Abdominal Devices

  • Nasogastric Tube: a small tube that goes through the nose and down the throat into the stomach. This is used to suction out stomach contents, give liquid feedings, or give medications.
  • Orogastric Tube: a small tube that goes through the mouth and down the throat into the stomach. This is used to suction out stomach contents, give liquid feedings, or give medications.
  • PEG Tube: a small tube that goes through the stomach and into the small intestine.
  • Gastrostomy Tube: a small tube that goes through the stomach and into the small intestine.
  • Jejunostomy Tube: a small tube that goes through the jejunum (part of the small intestine)
  • Colostomy: a small opening in the abdomen that goes to the large intestine or colon. A bag is placed over this opening to collect stool.
  • Ileostomy: a small opening in the abdomen that goes to the ileum (part of the small intestine)

It is good to know if the tube is patent, connected to suction, the color of the drainage, and the amount of drainage.

Bowel Continence

  • Incontinence is the inability to control bowel movements or gas. This can be due to a variety of causes such as diarrhea, constipation, infection, or nerve damage.
  • Fecal Impaction is when stool hardens and becomes stuck in the intestines. This can be extremely painful and can cause uncontrolled leaking around the impaction.
  • Flexi-Seal Device: a small, soft, silicone plug that is inserted into the rectum to help control incontinence.

Nutrition Assessment

Calorie and protein needs are increased in the ICU due to the stress of illness, injury, or surgery.

  • Enteral nutrition: liquid nutrition that is given through a nasogastric, orogastric, gastrostomy, or jejunostomy tube. This can be given continuously or in boluses (amounts).
  • Parenteral nutrition: liquid nutrition that is given through an IV. This can be given continuously or in boluses (amounts). Some mixtures require lipids while others do not.
  • Thickened Liquids: liquids that have been thickened with a powder to help with dysphagia (difficulty swallowing). This can include honey, nectar, or pudding-like consistencies.
  • Pureed Foods: foods that have been blended or mashed to a smooth consistency
  • Full Liquid: any liquid consistency including milk, cream, juice, decaffeinated coffee or tea, gelatin desserts, water
  • Clear Liquid: water, ice chips, clear broths, carbonated beverages
  • Regular: solid foods that have been chopped, diced, or minced
  • NPO: nothing by mouth. Most ICU patients will be NPO.

Genitourinary Assessment

Urine Assessment

  • Continence: the ability to control urination
  • Incontinence: the inability to control urination. This can be due to a variety of causes such as an enlarged prostate, urinary tract infection, nerve damage, or medications.
  • Foley Catheter: a small tube that is inserted into the bladder through the urethra to help with urinary incontinence or retention.
  • Urine Output: the amount of urine that is produced in a given time period. This is usually monitored hourly.
  • Clear Urine: urine that is clear or pale yellow in color
  • Dark Urine: urine that is dark yellow, brown, or red in color. This can be a sign of dehydration, liver disease, or kidney disease.
  • Blood in Urine: this can be a sign of infection, kidney disease, or cancer.
  • Cloudy Urine: this can be a sign of infection or kidney stones.
  • Sediment in Urine: this can be a sign of infection, kidney disease, or yeast infections.

Intake and Output Assessment

Fluid balance is monitored closely in the ICU. This includes all liquids that are taken in (by mouth, feeding tube, or IV) and all liquids that are lost (urine, stool, sweat, etc.).

  • Intake: the amount of fluids that are taken in by mouth, feeding tube, or IV. This is usually measured in mL/hour.
  • Output: the amount of fluids that are lost through urine, stool, sweat, etc
  • Fluid Restriction: when a patient is ordered to take in a certain amount of fluid per day. This is usually done to prevent excess fluid buildup in the body.

It is very important to monitor fluid balance closely in the ICU as even a small change can be detrimental to the patient’s health. You will find when there is a change in the patient’s condition, one of the first organs to become affected by the change is the kidneys.

musculoskeletal assessment

Musculoskeletal Assessment

Mobility Assessment

  • Bedrest: when a patient is ordered to stay in bed. Most ICU patients will be on bedrest restrictions.
  • Bed Pan or Bedside Commode: when a patient is unable to get out of bed to use the bathroom, a bedpan or bedside commode can be used.
  • Transfer: when a patient is moved from one surface to another (i.e. from bed to wheelchair)
  • Dangle: when a patient is allowed to sit at the edge of the bed with their feet dangling over the side
  • Up in Chair: when a patient is allowed to sit in a chair for a certain amount of time each day
  • Ambulation with assistance: when a patient is able to walk with the help of another person or a device such as a cane, walker, or crutches
  • Independent: when a patient is able to walk without the help of another person or a device

Ambulatory Assistive Devices

  • Gait Belt: a belt that is worn around the waist to help with transfers
  • Cane: a device that is used to help with balance when walking
  • Walker: a device that is used to help with balance and support when walking
  • Crutches: devices that are used to help with balance and support when walking. They are placed under the arms and the patient walks with them.
  • Braces: devices that are used to support joints or limbs. They can be made of metal, plastic, or fabric.
  • Wheelchair: a device that is used to help with mobility. It can be manual or motorized.
  • Hoyer Lift: a device that is used to help with transfers. It consists of a sling and a motor motorized lift.
  • Sara Stedy: a device that is used to help with balance when walking. It consists of a handle and a strap that goes around the waist. There is a seat that comes down that allows the patient to stay seated while being transferred.
  • Sara Flex: a device that is used to help with balance when standing. It consists of a handle and a strap that goes around the waist. There is also a strap that wraps around the ankles to keep the patient secure.

Circulation and Pulse Assessment of the Extremities

  • Color: should be pink
  • Paleness: may be a sign of anemia or poor circulation
  • Mottled: the skin looks like it has a mottled appearance and is usually a sign of poor circulation
  • Edema: swelling of the extremities
  • Claudication: pain in the extremities with movement, may be a sign of peripheral artery disease
  • Pulse: should be regular and equal in all extremities
  • Temperature: should be warm to the touch. If the extremities are cold, this can be a sign of poor circulation. If the extremities are hot, this can be a sign of infection or inflammation.
  • Capillary Refill: should be less than two seconds
  • Antiembolitic Hose Stockings: these are compression stockings that are worn to help with circulation. They are usually knee-high or thigh-high.

Contractures and Amputation Assessment

  • Contractures: when the muscles and joints of the extremities are stiff and unable to move. This can be a result of disuse or prolonged bed rest.
  • Amputation: when a body part is removed. This can be partial or complete.

Range of Motion Assessment

Should be done on all joints of the extremities.

  • Active Range of Motion: when the patient is able to move the joint on their own
  • Active Assisted Range of Motion: when the patient is able to move the joint with the help of another person
  • Passive Range of Motion: when the therapist or another person moves the joint for the patient
  • Continuous Passive Motion (CPM): when a machine is used to move the joint for the patient

Risk for Falls

All Intensive Care Patients are considered a high risk for falls. You should be talking about this during the bedside report.

  • Bed alarm: an alarm that goes off when the patient gets out of bed
  • Chair alarm: an alarm that goes off when the patient gets out of their chair
  • 1 to 2 person assist: when the patient needs help from one or two people to get out of bed or chair
  • Floor pad: these are placed around the bed and chair to help cushion any falls
  • Side rails: these are placed on the bed to help keep the patient from falling out. Remember that all four side rails up are considered a restraint in many states.
  • Mechanical Lift: a device that is used to help transfer the patient from the bed to a chair or wheelchair by way of a sling.
  • Slide Board: a device that is used to help transfer the patient from the bed to a chair or wheelchair by way of sliding.

Integumentary Assessment

You will perform an integumentary assessment as you move down the body during your assessment assessing for pallor, rashes, bruises, lesions, and scars.

Wound Assessment

  • Wound type: incisions, lacerations, abrasions, punctures, avulsions (when a body part is completely torn off)
  • Wound Size: length, width, and depth
  • Tunneling or Undermining: when the wound goes under the skin
  • Wound Color: red, pink, purple, black, brown, tan, yellow
  • Wound Temperature: should be warm to the touch
  • Wound Drainage: serosanguineous (mix of blood and clear fluid), serous (clear fluid), sanguineous (fresh blood), purulent (pus), seropurulent (mix of pus and blood)
  • Eschar: black or brown dead tissue that is usually a sign of a third-degree burn
  • Slough: yellow or white dead tissue that is usually a sign of a second-degree burn
  • Pressure Ulcer: when the skin and tissue breaks down due to sitting or lying in one position for too long. The most common places for pressure ulcers are the heels, sacrum, and coccyx.
  • Surgical site: site where an incision was made into the skin
  • Staples: a metal device used to close the skin and are usually removed within seven to fourteen days
  • Sutures: string devices used to close the skin or hold medical devices in place
  • Steristrips: sterile pieces of medical tape to close wounds and hold the edges of the skin together. These strips will fall off on their own in seven to ten days.
  • Dressing: a sterile material used to cover and protect the wound. This can be gauze, wet to dry dressing, alginate, hydrocolloid, or film.
  • Drainage: any fluid that is coming from the wound

Devices and Drains of the ICU

  • Jackson-Pratt: a small tube with a bulb placed in the wound that drains any fluid. The fluid is pulled out of the body with negative pressure when the bulb is compressed.
  • Hemovac: a larger tube with a collapsable cylinder on the end placed in the wound that drains any fluid. The fluid is pulled out of the body with negative pressure when the cylinder is compressed and can typical hold more fluid than the JP drain.
  • Penrose: a soft, flat, flexible tube made of latex that lets blood and other fluids move out of the surgical site.
  • Negative Pressure Wound Therapy (NPWT): a medical device that helps remove fluids from the wound and promote healing.
  • Chest Tubes: tubes that are placed in the chest to help remove air or fluid from the pleural cavity.
  • Arterial Line: a tube that is placed in an artery to measure blood pressure, heart rate, and oxygen levels.
  • Central Venous Catheters (CVC): a long, thin tube that is placed in a large vein near the heart. This is used to give fluids, blood, or medications.
  • Peripherally Inserted Central Catheter (PICC): a long, thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart. This is used to give fluids, blood, or medications.
  • Hickman: a type of CVC that has a small disk on the end that is placed under the skin. This is used mostly for chemotherapy.
  • Swan Ganz Catheter: a type of CVC that has a balloon on the end. This is used to measure the pressure in the heart and lungs.
  • Endotracheal Tube: a tube that is placed through the nose or mouth and goes down the trachea (windpipe) to help with breathing.
  • Intracranial Pressure Monitor: a tube that is placed in the brain to help measure the pressure inside the skull.
patient room precaution

Isolation Precautions

  • Contact Precautions: when a patient is placed in a private room and all visitors must wear gloves, gowns, and masks. Hands must be washed with either hand sanitizer or soap/water. Common diseases that require contact precautions are MRSA and VRE.
  • Droplet Precautions: when a patient is placed in a private room and all visitors must wear a mask. Hands must be washed with either hand sanitizer or soap/water. Common diseases that require droplet precautions are influenza, meningitis, and pneumonia.
  • Airborne Precautions: when a patient is placed in an airborne isolation room and all visitors must wear an N95 respirator mask, gown, and gloves. Hands must be washed with either hand sanitizer or soap/water. The door to the room must be kept closed. Common diseases that require airborne precautions are tuberculosis, COVID-19, and chickenpox.
  • C. Diff Precautions: when a patient is placed in a private room and all visitors must wear gloves and gowns. Hands must always be washed with soap/water.
  • Neutropenic Precautions: when a patient’s white blood cell count is low and they are at risk for infection. The patient is placed in a private room and all visitors must wear gloves and a mask. Hands must always be washed with soap/water.

Psychosocial Assessment

Behavior

  • Cooperative: the patient is willing to answer questions and follow directions
  • Uncooperative: the patient is unwilling to answer questions or follow directions
  • Agitated: the patient is restless, anxious, or angry
  • Pleasant: the patient is happy, friendly, or smiling
  • Withdrawn: the patient is quiet, does not make eye contact, or seems sad
  • Combative: the patient is fighting or trying to hurt someone else or themselves

Restraints

  • Chemical: medication that is given to help the patient calm down. Examples of medications that help calm patients are benzodiazepines (such as Ativan or Valium) and antipsychotics (such as Haldol or Zyprexa).
  • Physical: when the patient is tied to the bed with belts with the use of various physical restraints including vest restraints, mittens, side rails, and bed rails.

Vital Signs Assessment

  • Blood Pressure: the force of your blood against the walls of your arteries. This is measured with two numbers, systolic (the top number) and diastolic (the bottom number).
  • Mean Arterial Pressure (MAP): the average blood pressure during one heart beat. You will want to keep the MAP above 60-65 in most facilities.
  • Heart Rate: the number of times your heart beats in one minute. This is measured in beats per minute (bpm).
  • Respiratory Rate: the number of times you breathe in one minute. This is measured in breaths per minute (bpm).
  • Oxygen Saturation: how much oxygen your blood is carrying. This is measured as a percentage.
  • Temperature: the measure of your body’s heat. This is measured in Fahrenheit or Celsius.
  • Central Venous Pressure (CVP): the pressure of blood in the vena cava or the right atrium. This estimates preload and right atrial pressure.
  • Systemic Vascular Resistance (SVR): the resistance (force) to blood flow in the arteries. This is affected by afterload.
  • Cardiac Output (CO): the amount of blood that the heart pumps in one minute. This is affected by heart rate and stroke volume.
  • Stroke Volume (SV): the amount of blood pumped out of the left ventricle with each beat. This is affected by preload, afterload, and contractility.
  • Pulmonary Artery Occlusion Pressure (PAOP): the pressure in the pulmonary artery. This estimates left atrial pressure and help differentiate between cardiac and non-cardiac pulmonary edema.

Conclusion

The intensive care head-to-toe assessment is a comprehensive checklist that should be used when caring for critically ill patients. This assessment includes everything from the patient’s vital signs to their mental status. It is important to remember that each patient is unique and will require different levels of care.

Whether you are a nurse, doctor, or other healthcare professional, it is important to be familiar with this assessment so that you can provide the best possible care for your patients.