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NURC 1021 Head to Toe Patient Assessment
- Institution
- Eastern Florida State College
Detailed assignment on Head to Toe Patient Assessment for NURC 1021.
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Head to Toe Physical AssessmentPOLST/Code Status VS 7:30 Temperature Pulse Respirations BP / Pain /10
VS 11:30 Temperature Pulse Respirations BP / Pain /10
GENERAL SURVEY
Age___________ Male/Female Body Build: Thin Cachectic Obese WNL
How does the client look? Height___________ Weight____________ Well groomed Poorly Groomed
Facial Expression: Anxious Happy Sad Angry
NEUROLOGICAL
(LOC) Level of Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate
Consciousness Oriented x 4: Person Place Time Event Response to touch/voice
Eyes Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind
Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual
Pupils
Pupil size before light ______mm Pupil size after light ______mm
Ears Unaided hearing Hard of hearing Deaf Hearing aid Implant Cerumen Drainage
Extremities Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste)
Cranial Nerves - intact
VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue movement)
Pain Character Onset Location Duration Severity Pattern Associated Factors COLDSPA
CARDIOVASCULAR
Skin / Mucous Membranes Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic
Radial and Pedal Pulses Radial: Palpable (L/R) Absent (L/R) Pedal: (DP PT) Palpable (L/R) Absent (L/R)
Apical Radial Pulses (2 people simultaneously) Apical and Radial Pulse Deficit
Carotid Pulses (DO NOT TAKE AT SAME TIME) Right Left Thrill Bruit
Capillary Refill Normal (<3 Sec) ______sec
Jugular Neck Veins Not visible Visible
Edema Absent Present: location +1 +2 +3 +4 Anasarca Pitting Non Pitting
Calf Tenderness Denies Positive Homan’s sign R L calf size R____ L_____ (team leader or charge nurse notified)
Heart Rhythm/ Regular Irregular Murmur Extra sounds Strong Faint Muffled
Sounds – S1S2 Telemetry: rhythm ___________________ Pacemaker Defibrillator location
Solution_______________ Rate ____ml/hr Pump
Site location (be specific) ______________________________________
IV
Site appearance: Clear Edema Erythema Tender Pallor
Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________
RESPIRATORY
Respirations Regular Irregular Even Uneven Unlabored Labored Symmetrical Asymmetrical
Clear LUL RUL LLL RLL RML Anterior Posterior
Wheezes location__________ Rales/crackles location__________ Rhonchi location ________
Lung Sounds
Nasal flaring Sternal retraction Intercostal retraction
Do lung sounds improve with cough and deep breath? If no, report to team leader
Cough None Nonproductive Dry Moist Productive Sputum:amount color frequency
Room air Pulse ox ______ O2 at_____L/min Nasal Cannula Mask
Oxygen
Tent CPAP BIPAP
Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds # of times______
Respiratory Treatments
HHN medication Bipap Ventilator? TV rate 02% other
BLOOD GLUCOSE
ALLERGIES
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