"Head to Toe Physical Assessment Form for Students"

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Head to Toe Physical Assessment
POLST/Code Status
VS
7:30
Temperature
Pulse
Respirations
BP
/
Pain
/10
VS
11:30 Temperature
Pulse
Respirations
BP
/
Pain
/10
GENERAL SURVEY
Age___________
Male/Female
Body Build: Thin
Cachectic
Obese
WNL
How does the client look?
Height___________ Weight____________
Well groomed
Poorly Groomed
Facial Expression:
Anxious
Happy
Sad
Angry
NEUROLOGICAL
Alert
Awake
Lethargic
Obtunded
Stuper
Comatose
Confused
Decerebrate
Decorticate
(LOC) Level of
Consciousness
Oriented x 4:
Person Place Time Event
Response to touch/voice
Eyes
Unaided sight
Glasses
Contact lens
Implants
Prosthesis
Snellen 20/
Blind
Equal
Round
Reactive to light
Accommodates
Sluggish
Brisk
Nonreactive to light
Consensual
Pupils
Pupil size before light ______mm Pupil size after light ______mm
Ears
Unaided hearing
Hard of hearing
Deaf
Hearing aid
Implant
Cerumen
Drainage
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
Onset
Location
Duration
Severity
Pattern
Associated Factors
COLDSPA
CARDIOVASCULAR
Skin / Mucous Membranes
Pink
Pale
Cyanotic
Jaundiced
Ruddy
Flushed
Diaphoretic
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)
______sec
Jugular Neck Veins
Not visible
Visible
Edema
Absent
Present: location
+1 +2 +3 +4 Anasarca
Pitting
Non Pitting
Calf Tenderness
Denies
Positive Homan’s sign
R L calf size R____ L_____
(team leader or charge nurse notified)
Heart Rhythm/
Regular
Irregular
Murmur
Extra sounds
Strong
Faint
Muffled
Sounds – S1S2
Telemetry:
rhythm ___________________
Pacemaker
Defibrillator
location
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 Irregular
Even
Uneven
Unlabored
Labored
Symmetrical
Asymmetrical
Clear
LUL
RUL
LLL
RLL
RML
Anterior
Posterior
Wheezes location__________
Rales/crackles location__________
Rhonchi
location ________
Lung Sounds
Nasal flaring
Sternal retraction
Intercostal retraction
Do lung sounds improve with cough and deep breath? If no, report to team leader
Cough
None
Nonproductive
Dry
Moist
Productive
Sputum:amount
color
frequency
Room air
Pulse ox ______
O2 at_____L/min
Nasal Cannula
Mask
Oxygen
Tent
CPAP
BIPAP
Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds
# of times______
Respiratory Treatments
HHN
medication
Bipap
Ventilator? TV
rate
02%
other
BLOOD GLUCOSE
ALLERGIES
Head to Toe Physical Assessment
POLST/Code Status
VS
7:30
Temperature
Pulse
Respirations
BP
/
Pain
/10
VS
11:30 Temperature
Pulse
Respirations
BP
/
Pain
/10
GENERAL SURVEY
Age___________
Male/Female
Body Build: Thin
Cachectic
Obese
WNL
How does the client look?
Height___________ Weight____________
Well groomed
Poorly Groomed
Facial Expression:
Anxious
Happy
Sad
Angry
NEUROLOGICAL
Alert
Awake
Lethargic
Obtunded
Stuper
Comatose
Confused
Decerebrate
Decorticate
(LOC) Level of
Consciousness
Oriented x 4:
Person Place Time Event
Response to touch/voice
Eyes
Unaided sight
Glasses
Contact lens
Implants
Prosthesis
Snellen 20/
Blind
Equal
Round
Reactive to light
Accommodates
Sluggish
Brisk
Nonreactive to light
Consensual
Pupils
Pupil size before light ______mm Pupil size after light ______mm
Ears
Unaided hearing
Hard of hearing
Deaf
Hearing aid
Implant
Cerumen
Drainage
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
Onset
Location
Duration
Severity
Pattern
Associated Factors
COLDSPA
CARDIOVASCULAR
Skin / Mucous Membranes
Pink
Pale
Cyanotic
Jaundiced
Ruddy
Flushed
Diaphoretic
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)
______sec
Jugular Neck Veins
Not visible
Visible
Edema
Absent
Present: location
+1 +2 +3 +4 Anasarca
Pitting
Non Pitting
Calf Tenderness
Denies
Positive Homan’s sign
R L calf size R____ L_____
(team leader or charge nurse notified)
Heart Rhythm/
Regular
Irregular
Murmur
Extra sounds
Strong
Faint
Muffled
Sounds – S1S2
Telemetry:
rhythm ___________________
Pacemaker
Defibrillator
location
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 Irregular
Even
Uneven
Unlabored
Labored
Symmetrical
Asymmetrical
Clear
LUL
RUL
LLL
RLL
RML
Anterior
Posterior
Wheezes location__________
Rales/crackles location__________
Rhonchi
location ________
Lung Sounds
Nasal flaring
Sternal retraction
Intercostal retraction
Do lung sounds improve with cough and deep breath? If no, report to team leader
Cough
None
Nonproductive
Dry
Moist
Productive
Sputum:amount
color
frequency
Room air
Pulse ox ______
O2 at_____L/min
Nasal Cannula
Mask
Oxygen
Tent
CPAP
BIPAP
Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds
# of times______
Respiratory Treatments
HHN
medication
Bipap
Ventilator? TV
rate
02%
other
BLOOD GLUCOSE
ALLERGIES
GASTROINTESTINAL
Oral
Teeth
Dentures
Caries
Dysphagia
Mucous Membranes:
intact
moist
dry
pale
leukoplakia
Abdomen:
Inspect
Soft
Round
Flat
Scaphoid
Obese
Firm
Hard
Nondistended
Distended
Tender
Non Tender
Auscultate Percuss Palpate
Location:
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
Size
Consistency
Ostomy
Stool
Diet___________
% eaten Breakfast____ Lunch_____ NPO? Why___________
Nutrition
Self feed
Needs assistance
Thickened liquids: honey nectar
pudding
Tube Feed_________________
GENITOURINARY
Continent
Incontinent
Catheter type _______________
Patent
Nonpatent________________
Urine
Color_________________ Clear
Cloudy
Sediment
Burning
Frequency
PO/Oral/Tube Feed intake____________
IV intake____________
Urine output_________
Other output
Intake and Output
Fluid restriction
Total I&O + /- ________________
Genitalia
Male
Female
vaginal discharge
LMP
post partum
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_________
Pressure Ulcers
Wound appearance
Drain type _________ Amount______
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
Chemical
Physical: type
location
Restraints
CMST of extremity RA
LA
RL
LL
Frequency Checked________________
See Restraint Form
Language spoken
English = speaks and understands
other_________________ Interpreter
STUDENT(printed)__________________________________________________Date_________Client initials ________Room Number_______
NANDA DX ____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Medical DX_____________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
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