Head to Toe Patient Assessment PDF

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Summary

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Description

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

Unaided hearing

Extremities

Hand grips

Pain

Stuper

Contact lens

Reactive to light

Comatose

Confused

Decerebrate

Decorticate

Response to touch/voice Implants

Prosthesis

Accommodates

Snellen 20/

Sluggish

Brisk

Blind

Nonreactive to light

Consensual

Pupil size before light ______mm Pupil size after light ______mm

Ears

Cranial Nerves - intact

Obtunded

Person Place Time Event

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

Radial and Pedal Pulses

Radial: Palpable (L/R)

Pale

Cyanotic

Apical Radial Pulses

(2 people simultaneously)

Carotid Pulses

(DO NOT TAKE AT SAME TIME)

Capillary Refill

Normal (...