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Head to Toe Patient Assessment Cheat Sheet, Cheat Sheet of Nursing

A form for nurses to be filled by asking all the questions from patient

Typology: Cheat Sheet

2020/2021
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Uploaded on 04/23/2021

shashwat_pr43
shashwat_pr43 🇺🇸

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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
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Head to Toe Physical Assessment

POLST/Code Status VS 7:30 Temperature Pulse Respirations BP / Pain / VS 11:30 Temperature Pulse Respirations BP / Pain /

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 – S1S

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

GASTROINTESTINAL

Oral Teeth Dentures Caries Dysphagia Mucous Membranes: intact moist dry pale leukoplakia Abdomen: Inspect Auscultate Percuss Palpate

Soft Round Flat Scaphoid Obese Firm Hard Nondistended Distended Tender Non Tender Location: Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive Absent

NG/ GT/ JT

None Type of tube _____ patent nonpatent Suction: low high Color of drainage amount Bowel Movement Continent Incontinent last BM Color Size Consistency Ostomy Stool

Nutrition

Diet___________ % eaten Breakfast____ Lunch_____ NPO? Why___________ Self feed Needs assistance Thickened liquids: honey nectar pudding Tube Feed_________________

GENITOURINARY

Urine Continent^ Incontinent^ Catheter type _______________^ Patent^ Nonpatent________________ Color_________________ Clear Cloudy Sediment Burning Frequency

Intake and Output PO/Oral/Tube Feed intake____________^ IV intake____________^ Urine output_________^ Other output Fluid restriction Total I&O + /- ________________ Genitalia Male Female vaginal discharge LMP post partum

MUSCULOSKELETAL

Mobility ADLs independent or assisted with _________________________________________________ Muscle treatment None Cast Brace Splint Location Elevate Traction - type traction wt:

CMST Circulation: color, pulses, cap refill^ Motion^ Sensation^ Temperature RA LA RL LL Antiembolitic Hose:knee/thigh Contractures Not present Present – which extremity? What % decreased? Amputation No Yes Location _______________________________ ROM AROM AAROM PROM CPM Limited location___________________

Mobility

Turns self Sits independently Dangles Stands independently Walks independently Ambulatory assistance: Gait belt Cane Walker Crutches Braces Wheelchair Gerichair Walks: distance frequency tolerance PT OT RNA Risk for Falls Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side Rails Mechanical Lift Slide Board

INTEGUMENTARY

Appearance

Intact Color___________ Pallor Rash Bruise Lesions Scar Location _________________________ Turgor_____seconds Site___________ Skin Warm Hot Cool Cold Dry Moist Wound Dressing

Pressure Ulcers

None Surgical site – Location Well approximated Sutures Staples Steristrips Dressing: Dry/intact Non-intact Change: yes no Drainage: Color Amount___________ Odor_________ Wound appearance Drain type _________ Amount______ Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough Stage Location Size Tunneling Eschar Slough

ISOLATION

Type Culture Site Type Culture Site

PSYCHOSOCIAL

Behavior Cooperative Uncooperative Pleasant Withdrawn Combative Other_______________

Restraints

None Chemical Physical: type location CMST of extremity RA LA RL LL Frequency Checked________________ See Restraint Form Language spoken English = speaks and understands other_________________ Interpreter

STUDENT(printed) __________________________________________________ Date _________ Client initials ________ Room Number _______ NANDA DX ____________________________________________________________________________________________________________


Medical DX_____________________________________________________________________________________________________________