Writing a head to toe assessment documentation

Ask patient to close eyes and identify whether the sensation they are feeling is sharp or dull. The areas of assessment you need to focus on depend on what is wrong with your particular patient. Extremities The extremities are symmetrical in size and length.

Look at Tonsils Depress tongue to inspect tonsils for inflammation, infection, swelling and tonsil stones.

Complete Head-to-Toe Physical Assessment Cheat Sheet

You should no longer hear the brachial pulse through the stethoscope. Thyroid gland nonvisible but palpable when swallowing. Has a history of constipation.

Bowel sounds active in all 4 quads, abd non-tender to palpation. Move the penlight or finger out to the six cardinal positions of the gaze, moving back into the center before proceeding to the next one like you are drawing out a compass rose.

The pupils of the eyes are black and equal in size. Inspect Teeth and Gums Assess patient teeth for number 28 in children, 32 in adultscolor, and alignment. Nasal septum slightly deviated to the left, but does not obstruct airflow. I bet they have complete range of motion and strength in their lower extremities.

Repeat with other nostril. No pain or tenderness on palpation. Have them repeat with the other eye. Temporal artery elastic and nontender.

No dimpling, retraction, lesions, or inflammation noted. Palpate the thorax for any areas of tenderness, lumps, asymmetry, lesions, etc. Visual fields full by confrontation.

This is an example of a head-to-toe narrative assessment note. Cornea is transparent, smooth and shiny and the details of the iris are visible.

Allow the cuff to deflate gradually. Strength should be equal bilaterally. No lesions or excoriations noted. This tests cranial nerve X. Listen to 4 Quadrants of Abdomen for Bowel Sounds Visually dividing the abdomen into four quadrants with the belly button as the midline, listen to bowel sounds in each quadrant.

Examine Tongue Tongue should be midline, pink with white taste buds, and free of lesions. For the Rinne teststrike the tuning fork and place the base against the mastoid process.Oct 24,  · This entry was posted in Uncategorized and tagged Charting Examples, Documentation, Narrative, Nursing Note, Physical Assessment, Student Nurse by Heather Swift.

Bookmark the permalink. The areas of assessment you need to focus on depend on what is wrong with your particular patient. 10/4/96 86 y.o. male admitted 10/3/96 for L CVA.

V/S T,20, / Head to Toe Documentation 0 l. Peripheral vascular system lietuvosstumbrai.com n. Abdomen o. Genital p. Rectum q. Lymphatic r. Musculoskeletal s. Neurological 4. Health Assessment a.

General Survey b. Measurement / vital signs c. Integumentary lietuvosstumbrai.com signs of rashes, lesions, ecchymosis, discolorations d. Head To Toe Assessment – Guide & Documentation Cheat Sheet For Head To Toe Nursing School Tips Nursing School Graduation Nursing Notes Nursing Tips Nursing Board Lpn Schools Nursing Schools Nursing Students Rn Nurse.

This is an example of a head-to-toe narrative assessment note. I have my first-semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.

Head-to-Toe Assessment: Complete 12-Step Checklist

Jun 30, '07 by VickyRN Here is a head-to-toe narrative charting template that I developed for my first semester RN students last semester: 2/12/ 86 y.o. male admitted 2/1/07 for left CVA.

VS C, HR 97, RR 22, BP //5(1).

Writing a head to toe assessment documentation
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