Head to Toe Physical Assessment POLST/Code Status VS 7:30 Temperature Pulse Respirations BP 11:30 Temperature Pulse Respirations / BP Pain Male/Female Obese /10 VS Pain /10 / GENERAL SURVEY Age___________ How does the client look? Body Build: Thin Height___________ Weight____________ Facial Expression: Anxious Happy Cachectic Well groomed Sad WNL Poorly Groomed Angry NEUROLOGICAL (LOC) Level of Consciousness Alert Awake Lethargic Obtunded Oriented x 4: Person Place Time Event Eyes Unaided sight Pupils Equal Consensual Glasses Stuper Comatose Confused Response to touch/voice Contact lens Round Implants Reactive to light Prosthesis Decerebrate Snellen 20/ Accommodates Sluggish Decorticate Blind Brisk Nonreactive to light Pupil size before light ______mm Pupil size after light ______mm Ears Unaided hearing Extremities Hand grips Hard of hearing +1 +2 +3 +4 +5 I(smell) II(vision) Cranial Nerves - intact VIII (hear/balance) Pain Character Deaf Hearing aid equal unequal Foot pushes III+IV+VI(eye movement) IX (taste/swallow) Onset Location Implant +1 +2 +3 +4 +5 V(sensation of face/oral) X (chew/gag/speech) Duration Cerumen 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 Murmur Extra sounds rhythm ___________________ Rate Site location (be specific) Site appearance: Clear Pitting R L calf size R____ L_____ Solution_______________ IV Jaundiced (team leader or charge nurse notified) Strong Faint Pacemaker ____ml/hr Non Pitting Muffled Defibrillator location Pump ______________________________________ Edema Erythema Dialysis access: type __________ Thrill Tender Bruit Pallor Location:___________ Appearance:____________ RESPIRATORY Respirations Regular Irregular Clear Lung Sounds LUL Even RUL Uneven LLL Unlabored RLL RML Labored Anterior Symmetrical Posterior Wheezes location__________ Rales/crackles location__________ Nasal flaring Intercostal retraction Sternal retraction Asymmetrical Rhonchi location ________ Do lung sounds improve with cough and deep breath? If no, report to team leader Cough Oxygen None Nonproductive Room air Tent Dry Moist Pulse ox ______ CPAP BIPAP Productive Sputum:amount O2 at_____L/min color Nasal Cannula frequency Mask Incentive Spirometer (IS): ml______ frequency _______hold for ___ seconds Respiratory Treatments HHN medication Bipap Ventilator? TV rate # of times______ 02% other BLOOD GLUCOSE ALLERGIES GASTROINTESTINAL Oral Teeth Abdomen: Inspect Dentures Caries Dysphagia Flat Scaphoid Auscultate Percuss Palpate Soft Round Location: Bowel Sounds RLQ LUQ LLQ RUQ None NG/ GT/ JT Bowel Movement high Continent Firm patent Hard intact moist Nondistended Hypoactive dry Distended Hyperactive pale leukoplakia Tender Non Tender Absent nonpatent Color of drainage Incontinent Diet___________ Nutrition Obese Normoactive Type of tube _____ Suction: low Mucous Membranes: 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 CMST Cast Brace RA LA Amputation No Yes ROM AROM AAROM Turns self Elevate Motion RL Not present Traction - type Sensation LL traction wt: Temperature Antiembolitic Hose:knee/thigh Present – which extremity? What % decreased? Location _______________________________ PROM CPM Sits independently Limited location___________________ Dangles Ambulatory assistance: Gait belt Walks: distance Risk for Falls Location Circulation: color, pulses, cap refill Contractures Mobility Splint Cane Stands independently Walker frequency Crutches Braces tolerance Bed alarm Chair alarm 1 or 2 Person Transfer Floor pad Walks independently Wheelchair Gerichair PT OT RNA Side Rails Mechanical Lift Slide Board INTEGUMENTARY Appearance Intact Color___________ Pallor _________________________ Turgor_____seconds Skin Warm Wound Dressing None Bruise Lesions Scar Location Site___________ Hot Cool Cold Surgical site – Location Dry Moist Well approximated Dressing: Dry/intact Non-intact Pressure Ulcers Rash Sutures Staples Steristrips Change: yes no Drainage: Color Amount___________ Odor_________ Wound appearance Stage Location Drain type _________ Amount______ 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 Withdrawn Combative Other_______________ location LL Frequency Checked________________ See Restraint Form other_________________ Interpreter STUDENT(printed)__________________________________________________Date_________Client initials ________Room Number_______ NANDA DX ____________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________ Medical DX_____________________________________________________________________________________________________________ ______________________________________________________________________________________________________________________