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

Download Head to Toe Patient Assessment Cheat Sheet and more Cheat Sheet Nursing in PDF only on Docsity! 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