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___________ How does the client look? Male/Female Body Build: Thin Height___________ Weight____________ Facial Expression: Anxious Happy Cachectic Obese Well groomed Sad WNL Poorly Groomed Angry NEUROLOGICAL Alert Awake (LOC) Level of Consciousness Oriented x 4: Eyes Unaided sight Pupils Equal Lethargic Glasses Round Confused Decerebrate Decorticate Response to touch/voice Contact lens Reactive to light Comatose Implants Prosthesis Accommodates Snellen 20/ Sluggish Brisk Blind Nonreactive to light Consensual Pupil size before light ______mm Pupil size after light ______mm Unaided hearing Extremities Hand grips Pain Stuper Person Place Time Event Ears Cranial Nerves - intact Obtunded Hard of hearing +1 +2 +3 +4 +5 I(smell) II(vision) VIII (hear/balance) Character Deaf Hearing aid equal unequal III+IV+VI(eye movement) IX (taste/swallow) Onset Location Implant Foot pushes V(sensation of face/oral) X (chew/gag/speech) Duration Cerumen +1 +2 +3 +4 +5 Severity Drainage equal unequal VII (facial movement/taste) XI (shrug/turn head) Pattern XII(tongue movement) Associated Factors COLDSPA CARDIOVASCULAR Skin / Mucous Membranes Pink Pale Cyanotic Radial and Pedal Pulses Radial: Palpable (L/R) Apical Radial Pulses (2 people simultaneously) Apical and Radial Carotid Pulses (DO NOT TAKE AT SAME TIME) Right Capillary Refill Normal (<3 Sec) Jugular Neck Veins Not visible Edema Absent Present: location Calf Tenderness Denies Positive Homan’s sign Heart Rhythm/ Regular Sounds – S1S2 Telemetry: Absent (L/R) Ruddy Pedal: (DP PT) Flushed Palpable (L/R) Diaphoretic Absent (L/R) Pulse Deficit Left Thrill Bruit ______sec Visible Irregular +1 +2 +3 +4 Anasarca Pitting R L calf size R____ L_____ Murmur Extra sounds rhythm ___________________ Solution_______________ IV Jaundiced Rate (team leader or charge nurse notified) Strong Faint Pacemaker ____ml/hr Muffled Defibrillator location Pump Site location (be specific) ______________________________________ Site appearance: Clear Erythema Edema Dialysis access: type __________ Thrill Tender Bruit Non Pitting Pallor Location:___________ Appearance:____________ RESPIRATORY Respirations Regular Irregular Clear Lung Sounds LUL Even RUL Uneven LLL Unlabored RLL RML Labored Anterior Symmetrical Wheezes location__________ Rales/crackles location__________ Nasal flaring Intercostal retraction Sternal retraction Asymmetrical Posterior Rhonchi location ________ Do lung sounds improve with cough and deep breath? If no, report to team leader Cough Oxygen Respiratory Treatments ALLERGIES None Nonproductive Room air Tent Dry Moist Pulse ox ______ CPAP Productive Sputum:amount O2 at_____L/min Nasal Cannula medication frequency Mask BIPAP Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds HHN color Bipap Ventilator? TV rate # of times______ 02% Blood Glucose other Gastrointestinal Oral Abdomen: Teeth Inspect Soft Dentures Round Caries Flat Dysphagia Scaphoid Mucous Membranes: Obese Firm Hard intact moist Nondistended dry Distended pale leukoplakia Tender Non Tender Auscultate Percuss Palpate Location: Bowel Sounds RLQ RUQ None NG/ GT/ JT LUQ high Continent patent Hypoactive Hyperactive Absent nonpatent Color of drainage Incontinent Diet___________ Nutrition Normoactive Type of tube _____ Suction: low Bowel Movement LLQ last BM amount Color Size Consistency Ostomy Stool % eaten Breakfast____ Lunch_____ NPO? Why___________ Self feed Needs assistance Continent Incontinent Thickened liquids: honey nectar pudding Tube Feed_________________ GENITOURINARY Urine Catheter type _______________ Color_________________ Clear Cloudy PO/Oral/Tube Feed intake____________ Intake and Output Fluid restriction Genitalia Male Sediment Patent Burning IV intake____________ Nonpatent________________ Frequency Urine output_________ Other output Total I&O + /- ________________ Female vaginal discharge LMP post partum MUSCULOSKELETAL Mobility ADLs independent or assisted with _________________________________________________ Muscle treatment None Cast Brace Splint Location Circulation: color, pulses, cap refill CMST RA LA RL Contractures Not present Amputation No Yes ROM AROM AAROM Turns self Mobility Traction - type Sensation LL traction wt: Temperature Antiembolitic Hose:knee/thigh Present – which extremity? What % decreased? Location _______________________________ PROM CPM Sits independently Walks: distance Limited location___________________ Dangles Ambulatory assistance: Gait belt Risk for Falls Elevate Motion Cane Stands independently Walker frequency Crutches Walks independently Braces tolerance Wheelchair Gerichair PT OT RNA Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Side Rails Mechanical Lift Slide Board integumentary Intact Appearance Color___________ Turgor_____seconds Skin Warm Wound Dressing None Pallor Bruise Lesions Scar Location _________________________ Site___________ Hot Cool Cold Dry Surgical site – Location Drainage: Color Moist Well approximated Dressing: Dry/intact Non-intact Pressure Ulcers Rash Staples Steristrips Change: yes no Amount___________ Wound appearance Sutures Odor_________ 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 Restraints Language spoken Cooperative None Uncooperative Chemical Pleasant Physical: type CMST of extremity RA LA RL English = speaks and understands LL Withdrawn Combative Other_______________ location Frequency Checked________________ See Restraint Form other_________________ Interpreter STUDENT(printed)__________________________________________________Date_________Client initials ________Room Number_______ NANDA DX ____________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Medical DX_____________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________