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Stack # 1315706

Head to Toe Assessment Checkoff

TermDefinition
NEURO/SENSORY - LOC Alert & Oriented X ________ 1)Person 2)Place 3)Time 4)Situation Lethargic/Drowsy/Confused/Forgetful/Unresponsive Sensations WNL Other ______________________
SPEECH/PUPILS/COMMUNICATION Clear/Understandable/Slurred/Nonverbal/Aphasia PERRL (L)___ (R)___ Coherent Conversation/Able to Grasp Ideas/Answers Questions Appropriately/Follows Instructions Other Obs.______________________
VISION/HEARING Vision WNL/Vision Impaired ___________ Hearing WNL/Hearing Impaired_____________ Other Obs._________________________
PAIN Pain Level _______ Location ________________ Intervention ___________________ Relief-Post Intervention Pain Level ______ Other Obs._______________________
CARDIOVASCULAR Heart Rate ____ Regular Irregular B/P ____/_____ Pulses-Present/Absent/Strong/Weak RRP-P/A/S/W LRP-P/A/S/W RPP-P/A/S/W LPP-P/A/S/W Nail Beds Pink CRT </> 3 sec Edema-Pitting Loc/Rating Non-Pitting Loc/Rating
RESPIRATORY Respiration Rate ___ Regular/Even/Unlabored/Labored/Shallow/Rapid O2 Sat ___% SOB (described) Breath Sounds & Loc - Clear/Equal, Rhonchi,Wheezes/Crackles Decreased or Diminished Cough Present - Y/N Productive/NonProductive Sputum____
GASTROINESTINAL Bowel Sounds: WNL(ActiveX4) Hypoactive/Hyperactive/Absent Abdomen: Soft/Firm/Hard/Distended/Tender LBM (described) ___________
DIET NPO/(diet) _________ Tolerates Well/Nausea/Vomiting(describe emesis) Dysphagia - Aspiration Precautions Tube Feeding ______ml/hr % of meals (B)_____(L)_____(D)______ Adequate/Inadequate Intake
RENAL/URINARY Voiding - Without Complaints/Dysuria/Frequency/Burning Continent/Incontinent Adequate/Inadequate Output Catheter Type ________ Patent&Draining _____ Color_____ Clarity_______ Sediment
MUSCULOSKELETAL (1st card) MAE Activity: Tolerates Well/Fatigue Activity: Amb per Self/Amb w/assist X____ Transfers per Self/Tranfers w/assist X___ Gait: Steady/Unsteady Assistive Devices___ Muscle Tone Normal/Fair/Poor/Flaccid RUE/RLE/LUE/LLE
MUSCULOSKELETAL (2nd card) Movement(normal/limited)-RUE/RLE/LUE/LLE Strength(strong or weak)-RUE/RLE/LUE/LLE ROM: Full/Limited/Passive (describe) Immobile (describe) ADL’s Independent/Total/Assist
SKIN Color - Pale/Pink/Ruddy/Grey/Jaundice/Cyanosis Skin Turgor - Normal/Sluggish/Loose Skin - Warm/Dry/Cool/Diaphoretic Skin Condition - Fragile/Thin/Intact/Impaired Mucus Membranes - Moist/Pink/Intact Redness/Rash/Wounds
PSYCHOSOCIAL Cooperative/Uncooperative Behavior Appropriate/Inappropriate Coping Well/Depression/Anxious
PRIOR TO ENTERING ROOM - WHAT DO YOU DO? Gather equipment needed for assessment a.Stethoscope b.Appropriate sized blood pressure cuff c.Pulse Oximeter d.Penlite e.Thermometer f.Gloves
UPON ENTERING ROOM - WHAT DO YOU DO? a.**Perform hand hygiene b.Identify self c.**Identify patient d.**Verify Allergies e.Assure privacy f.**Explain what is about to occur g.Allow for patient questions h.Raise bed to comfortable working height i.Don gloves
PRIOR TO LEAVING THE ROOM - WHAT DO YOU DO? 1.Check equip: a.IV-solution/rate/site b.O2-setting/type c.Drains(including foley) 2.Survey envir. for safety 3.Reposition pt 4.Lowerbed 5.Raise approp. rails 6.Call light/belongings in reach 7.**Hand Hygiene 8.Gather/Remove equipment
Created by: prich57
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