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Assessheet 122

The document provides a template for conducting a head-to-toe physical assessment of a patient. It includes sections to document the patient's vital signs, orientation, appearance of the head, neck, chest, abdomen, extremities, range of motion, sensation, pain levels, skin, and other general observations. The assessment addresses key body systems and potential medical issues to provide an overall picture of the patient's physical condition.

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Christine Goodpaster
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418 views2 pages

Assessheet 122

The document provides a template for conducting a head-to-toe physical assessment of a patient. It includes sections to document the patient's vital signs, orientation, appearance of the head, neck, chest, abdomen, extremities, range of motion, sensation, pain levels, skin, and other general observations. The assessment addresses key body systems and potential medical issues to provide an overall picture of the patient's physical condition.

Uploaded by

Christine Goodpaster
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Head-to-Toe Assessment Assessment conducted by LOC Alert Drowsy Lethargic StuporousComa Orientation Person Place Time Situation Vitals

itals Temp R BP Pulse Ox Head Hair PERLA Nose Ears Mouth o Midline tongue o Moist o Lesions o Dentition Neck Carotid pulse JVD + Trachea midline Chest Apical Pulse Muffled Arrhythmia Breath Sounds - Anterior Posterior Lateral Chest Symmetry Skin Turgor (clavicle) Abdomen Inspection Ausculation o LUQ (active / hyper o RUQ (active / hyper o LLQ (active / hyper o RLQ (active / hyper Palpation Upper Extremities

Date: Time: Radial pulses equal, +2 o Other: Temp vs. trunk (warm / cool) Grip equal and strong Capillary refill <3 sec Vein filling rapid

mm

Lower Extremities Hair present Edema Foot strength Homain's (+ / -) Claudication (+ / -) Temp vs. Trunk (warm / cool) Nails Yellowed Thickened Ingrown Pedal pulse R(palp / doppler) L(palp / doppler) ROM / Strength Upper R Upper R Upper L Upper L Lower R Lower R Lower L Lower L Sensation General Assessment Weight/Height BM Pain Assessment Acute/Chronic Intensity (0-10) Location Duration Characteristics Precipitation Frequency Non-verbals Relief factors Sleep Skin Assessment Description:

/ absent) / absent) / absent) / absent)

Courtesy of http://nursing.arizela.com

Courtesy of http://nursing.arizela.com

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