Head To Toe Patient Assessment - Pamilar

Head to Toe Physical Assessment
POLST/Code Status V 7:3 Temperature Pulse Respirations BP / Pain /10

S 0
V 4:0 Temperature Pulse Respirations BP / Pain 5 /10

S 0p 36.4 83 20 11
m 0/7
0
GENERAL SURVEY
Age 42 Female Body Build: Anorexic
Height Weight Well groomed

How does the client look?
Facial Expression: Anxious
NEUROLOGICAL
(LOC) Level of Alert Awake Oriented: Person Place Time Event Respond to touch & voice
Consciousness
Eyes NORMAL
Equal Round Reactive to light

Pupils
Pupil size before light mm Pupil size after light mm
Ears NORMAL
Extremities Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal
I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste)

Cranial Nerves - intact
VIII (hear/balance) IX (taste/swallow) X (chew/gag/speech) XI (shrug/turn head) XII(tongue
movement)
Pain Character: SHARP Onset Location : LRQ Duration: q5 Severity Pattern Associated Factors
COLDSPA
CARDIOVASCULAR
Skin / Mucous Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic

Membranes
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) 3 sec
Jugular Neck Veins Visible
Edema Absent
Calf Tenderness Denies Positive Homan’s sign R L calf size R L (team leader or charge nurse notified)
Heart Rhythm/ Regular

Sounds – S1S2
Solution Rate ml/hr Pump
Site location (be specific)

IV Site appearance: Clear Edema Erythema Tender Pallor
Dialysis access: type Thrill Bruit Location: Appearance:
RESPIRATORY
Respirations Regular
Clear
Lung Sounds
Cough NONE
NONE
Oxygen
Respiratory Treatments
NONE
ALLERGIES BLOOD GLUCOSE

GASTROINTESTINAL
Oral Teeth Dentures Caries Dysphagia Mucous Membranes: intact moist dry pale leukoplakia
Abdomen: Inspect Tender

Auscultate Percuss Location : Right lower quadrant
Palpate
Bowel Sounds RLQ RUQ LUQ LLQ Normoactive Hypoactive Hyperactive Absent
None Type of tube patent nonpatent

NG/ GT/ JT
Suction: low high Color of drainage amount
Bowel Movement Continent Incontinent last BM Color : BROWN Size Consistency: Ostomy
Stool
NPO
Nutrition
GENITOURINARY
Continent Incontinent Catheter type Patent Nonpatent

Urine
Color Clear Cloudy Sediment Burning Frequency
Intake: 1000ml Ouput: 250ml

Intake and Output
Fluid restriction Total I&O + /-
Genitalia Male Female vaginal discharge LMP postpartum
MUSCULOSKELETAL
Mobility ADLs independent or assisted with _________________________________________________
Muscle treatment None Cast Brace Splint Location Elevate Traction - type traction wt:
Circulation: color, pulses, cap refill Motion Sensation Temperature

CMST
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
Turns self Sits independently Dangles Stands independently Walks independently
Mobility 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
Intact Color Pallor Rash Bruise Lesions Scar Location
Appearance
Turgor seconds Site
Skin Warm Hot Cool Cold Dry Moist
Wound Dressing 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

Pressure Ulcers 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
None Physical: location

Restraints
Chemical type RA LA
Frequency Checked See Restraint Form
CMST of RL LL
extremity
Language spoken English = speaks and understands other Interpreter
STUDENT(printed) Date Client initials Room Number

NANDA DX
__________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Medical DX
_____________________________________________________________________________________________________________________________

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Head to Toe Physical Assessment

POLST/Code Status V 7:3 Temperature Pulse Respirations BP / Pain /10

V 4:0 Temperature Pulse Respirations BP / Pain 5 /10

Height Weight Well groomed

Equal Round Reactive to light

Extremities Hand grips +1 +2 +3 +4 +5 equal unequal Foot pushes +1 +2 +3 +4 +5 equal unequal

I(smell) II(vision) III+IV+VI(eye movement) V(sensation of face/oral) VII (facial movement/taste)

Skin / Mucous Pink Pale Cyanotic Jaundiced Ruddy Flushed Diaphoretic

Capillary Refill Normal (<3 Sec) 3 sec

Jugular Neck Veins Visible

Heart Rhythm/ Regular

Solution Rate ml/hr Pump

Site location (be specific)

Dialysis access: type Thrill Bruit Location: Appearance:

ALLERGIES BLOOD GLUCOSE

Abdomen: Inspect Tender

None Type of tube patent nonpatent

Continent Incontinent Catheter type Patent Nonpatent

Intake: 1000ml Ouput: 250ml

Genitalia Male Female vaginal discharge LMP postpartum

Circulation: color, pulses, cap refill Motion Sensation Temperature

Contractures Not present Present – which extremity? What % decreased?

Amputation No Yes Location

ROM AROM AAROM PROM CPM Limited location

Turns self Sits independently Dangles Stands independently Walks independently

Walks: distance frequency tolerance PT OT RNA

Skin Warm Hot Cool Cold Dry Moist

Dressing: Dry/intact Non-intact Change: yes no

Drainage: Color Amount Odor

Wound appearance Drain type Amount

None Physical: location

Language spoken English = speaks and understands other Interpreter

STUDENT(printed) Date Client initials Room Number

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