Head to Toe Physical Assessment
POLST/Code Status VS 7:30 Temperature Pulse Respirations BP / Pain /10
VS 11:30 Temperature Pulse Respirations BP / Pain /10
GENERAL SURVEY
How does the client look?
Age___________ Male/Female Body Build: Thin Cachectic Obese WNL
Height___________ Weight____________ Well groomed Poorly Groomed
Facial Expression: Anxious Happy Sad Angry
NEUROLOGICAL
(LOC) Level of
Consciousness
Alert Awake Lethargic Obtunded Stuper Comatose Confused Decerebrate Decorticate
Oriented x 4: Person Place Time Event Response to touch/voice
Eyes Unaided sight Glasses Contact lens Implants Prosthesis Snellen 20/ Blind
Pupils Equal Round Reactive to light Accommodates Sluggish Brisk Nonreactive to light Consensual
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
Cranial Nerves - intact I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste)
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/
Sounds – S1S2
Regular Irregular Murmur Extra sounds Strong Faint Muffled
Telemetry: rhythm ___________________ Pacemaker Defibrillator location
IV
Solution_______________ Rate ____ml/hr Pump
Site location (be specific) ______________________________________
Site appearance: Clear Edema Erythema Tender Pallor
Dialysis access: type __________ Thrill Bruit Location:___________ Appearance:____________
RESPIRATORY
Respirations Regular Irregular Even Uneven Unlabored Labored Symmetrical Asymmetrical
Lung Sounds
Clear LUL RUL LLL RLL RML Anterior Posterior
Wheezes location__________ Rales/crackles location__________ Rhonchi location ________
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
Oxygen Room air Pulse ox ______ O2 at_____L/min Nasal Cannula Mask
Tent CPAP BIPAP
Respiratory Treatments Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds # of times______
HHN medication Bipap Ventilator? TV rate 02% other
ALLERGIES BLOOD GLUCOSE
