Writing a head to toe assessment documentation

Patient should hear the sound of the tuning fork through the air in front of the air 2x longer than through the bone. There were no presence of discharges, no discoloration and lids close symmetrically with involuntary blinks approximately times per minute.

To check that they are reactive to light, dim the room and move the penlight back and forth between the eyes. At risk for aspiration related to dysphagia; on thickened dysphagia diet. The smooth palates are light pink and smooth while the hard palate has a more irregular texture.

Excessive flaring of the nostrils may indicate respiratory distress. Assess Range of Motion and Strength in Arms Have patient demonstrate range of motion in arms and hands.

Check Distribution and Condition of Hair Is hair healthy? Heart sounds clear and regular, patient has a history of heart disease and has an implanted pacemaker If your patient is on a heart monitor, record the rhythm here — such as normal sinus rhythm, A-fib ect.

Calf pumps x 5 bilateral encouraged every 2 hours while awake. Inspect patient abdomen for any visible lumps, lesions, or distension or concavity. Extremities The extremities are symmetrical in size and length. Left arm has limited mobility due to weakness secondary to CVA.

Part hair in several places on the scalp to check for bumps, sores, or scabs on the skin. There are also no signs of infection and infestation observed. Have them repeat with the other eye.

Bowel sounds active in all 4 quads, abd non-tender to palpation. Apical pulse regular rate and rhythm; s1, s2 noted.

Feet cool, dry, intact, with thick toenails bilateral.

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

Palpate the thorax for any areas of tenderness, lumps, asymmetry, lesions, etc. Homan's sign negative bilaterally. Is it thinning in places? Nailbeds pink without clubbing. Hold easily scented item like coffee beans, cinnamon, or even an alcohol-soaked cotton ball under the nose and ask patient to identify scent.

Glans is rounded, and free of lesions; urinary meatus is centrally located on glans; no discharge is palpated from urinary meatus. Axillae free of rashes or inflammation.

Free movement of breasts with position changes of arms and hands. If you do hear sounds, you may only need to listen for several seconds in each quadrant. This head-to-toe assessment video shows a particularly detailed assessment procedure performed by a nursing student.

Ventral surface of tongue smooth and shiny pink with small visible veins present. This example video shows a nursing student performing an efficient but thorough sample assessment.

Check for Symmetrical Facial Movements Have patient smile, frown, raise eyebrows, and puff out cheeks. The client blinks when the cornea was touched.


Frontal sinuses are palpable over patient eyebrows. Sternoclavicular joint midline with swelling or redness. Normal curves of cervical, thoracic, and lumbar spine. Measure Blood Pressure In professional settings, you may have an automatic blood pressure cuff or you may need to take blood pressure manually.

Moistness and Color of Lips Lips should be colorful, pinkish, roughly symmetrical, and free of lesions. There was no presence of discharge or flaring. No slurring of speech. Note any cavities or chips.

Complete Head-to-Toe Physical Assessment Cheat Sheet

Patient should be able to open and close mouth without pain and there should be no pain on palpation. Examine Tongue Tongue should be midline, pink with white taste buds, and free of lesions.

We also included several head-to-toe assessment videos so you can see the whole process in action! Lung sounds clear in all lung fields.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. A head-to-toe nursing assessment is a comprehensive process that reviews the health of all major body systems (from “head-to-toe,” hence the name).

head-to-toe assessments are usually performed by nurses as part of a physical exam, although physician assistants, EMTs, and doctors also sometimes perform head-to-toe assessments.

Head to Toe Documentation 0 l. Peripheral vascular system dominicgaudious.net n. Abdomen o. Genital p. Rectum q. Lymphatic r. Musculoskeletal s. Neurological 4. Health Assessment a. General Survey b. Measurement / vital signs c.

Integumentary dominicgaudious.net 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.

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, / 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.

Writing a head to toe assessment documentation
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