Basic Head To Toe Assessment 1 (144.12 KiB) Viewed 99 times
Basic Head To Toe Assessment 2 (149.43 KiB) Viewed 99 times
ASSESSMENT DATA Allergies PERSONAL INFORMATION Gender Age Height Weight Place of residence History of alcohol/drug use Support systems NURSING TREATMENTS AND PROCEDURES HEAD TO TOE ASSESSMENT CLINICAL DAY #1 Related Labs/Meds NEUROLOGICAL Orientation Speech Safely needs PERRLA Grips/foot pushes Sensory deficits We will not be completing this column for this assignment EMOTIONAL RESPONSE Anxiety Fear Anger Depression DISCOMFORT Pattern of discomfort Pain location & scale rating Interventions Patient response RESPIRATORY Lung sounds Respiratory rate Respiratory pattern Cough Secretions Oxygen use 02 saturation History of smoking CIRCULATION Blood pressure Pulse Capillary refill Heart rhythm/rate Edema Peripheral pulses S&S of DVT Blood Glucose Finger stick time/results Action taken
CLINICAL DAY #1 Related Labs/Meds SKIN/MUCOSA General appearance/color mucosa Incision appearance Skin turgor Dressings (type/location) IV SITE ASSESSMENT Type Location Site assessment IV fluids infusing NUTRITION Diet/% eaten TPN/PPN Nausealvomiting INTAKE Shift IV intake Shift PO intake/feedings 24 intake ELIMINATION Shift urine output 24 Output Foley/NG/Drains Bowel sounds Date of last BM Abdomen shape/distention IMMUNE Temperature S&S of infection MOBILITY Range of motion/CPM Limitations Assistive aids TEDS/Sequentials Activity Tolerance of Activity Self care needs TEACHING/LEARNING NEEDS FOR THE PATIENT AND/OR FAMILY ETHNICICULTURAL CONSIDERATIONS REFERRALS TO COMMUNITY AGENCIES
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