HEAS Documentation Head to Toe PDF

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HEAS 1000 STUDENT NAME

(please print): Lilly Sterner

Head to Toe Documentation

Client Care Record Date

25 Nov 2020

Tim e

1400

Nurse’s Notes

Received into care at 1340. Found laying in bed, side rails up x2, call bell in reach. Alert, oriented x4. Vital Signs taken on assessment, see flow sheet. Diagnosed with osteoarthritis and hypothyroidism in 2010. Allergies to dust and pollen resulting in bronchitis. Prescribed Synthroid 0.25 mg daily to increases thyroid hormone levels, not taken consistently. Occasionally takes Tylenol when arthritis is unbearable. Denies use of mood-altering drugs, supplements, birth control. Denies history of smoking. Complaint of pain in eyes, started this morning. Stated, “feels like I have sand in my eyes, and want to scratch my eyes out”. Denial of anything relieving pain. Stated she was “unable to open her eyes this morning as they were crusted and stuck closed.” Eyes are leaking greenish discharge. Nothing found to relieve pain. Also stated that her knees are bothering her today. Denies anything relieving pain. Denies family history of eye disease. Denies history of eye surgeries. Denies personal history of eye issues. Upon inspection, facial expression and body position are relaxed and comfortable. Adequate nutritional status and personal hygiene habits. Good articulation and content appropriate speech. Skin is warm, pink, dry. Even hair distribution, no presence of swelling, lesions, bruising. Nails are light pink and have the shape of convex curve with no clubbing present. Skin around eyes is intact, dry, and

Documentation Guidelines: Format:  Permanent black/ blue ink  Correct Date format: Day Month Year (e.g. 07 Feb 2016)  Time – use 24-hour clock (no colons or semi colons)  Signature (1st initial, last name and designation (eg. J Smith SPN )  Correct error appropriately (single line, initial, mistaken entry )  No blank spaces at the end of line or between entries  No abbreviations  For sequential page documentation, signature at bottom of 1st page. On second page, time, date and “continued”. Content:  Indicated how patient was found.  Indicated safety precautions (side rails & call bell in reach?) How was client left?  Did not use the word “patient” or “client” in charting.  Chronological/sequential manner  Subjective informationwhat the client says about herself or himself  Accurate documentation for inspection  Accurate information for palpation.  Accurate information for auscultation, or other key systems.  Correct spelling  No double charting (do not chart vitals unless abnormal, chart “Vital signs taken, see flow sheet”.  Document what you have done, not what you will do.

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flaky from secretions, eyelids close symmetrically and blinking is involuntary, sclera appears white. Glasgow coma scale completed, score 15. Both pupils of the eyes are round and equal in size, 5mm. Illuminated and non-illuminated pupils constricts, 3mm upon illumination, 4mm upon accommodation. Pupils constrict when looking at near object and dilate at far object. Obeyed commands for motor response, provided appropriate verbal responses. On room air, quiet, rhythmic, and effortless respirations. Absence of cough. No use of accessory muscles or visible labored breathing. The colour of chest equal, chest wall is intact, no visible lumps or masses. Full and symmetric expansion and deflation on inspiration and expiration. Colour over precordium even, no jugular venous distention no visible lumps, masses, pulsations, heaves, or thrills. No edema present. Denies experiencing straining or discomfort during bowel movements. Abdomen contour is slightly rounded, not distended. States she is voiding regularly, completely, and without stain. Muscles are symmetrical, even in colour, even contour, no presence of swelling or deformity in muscles or joint. Gait has slight limp from right knee. No intervention needed when walking. Upon palpation, skin equal bilaterally in temperature, soft and dry, adequate skin turgor. Capillary refill on all 20 digits assessed, blood return in under 3 seconds. Upper and Lower muscle strength assessed, both equal bilaterally. No tenderness is noted upon palpation of anterior and posterior chest wall. No pulsations felt. Apical Aug 26, 2020 V1.20

HEAS 1000

and radial pulses regular, strong, grade 2+. Posterior tibial and dorsalis pedis pulses palpated, easily detected, equal bilaterally, grade 2+. All four quadrants of abdomen palpated, soft, no masses or bumps palpable. No pain or rigidity noted. When palpating joints, no pain, crepitations, masses, or deformities felt. Minor swelling and pian felt in knee joints, temperature equal bilaterally. Limited range of motion in knees upon flexion, extension, and shallow knee bend test, grade 3, movement against gravity but not resistance. Upon Auscultation: Lung sounds are clear in all anterior and posterior lobes bilaterally, air entry into lungs equal, no adventitious breath sounds heard. Apical rate regular, regular S1 and S2, no S3 or S4 noted. Active bowel sounds heard in all quadrants. Received anti-allergy eye drops and pain medication. Remains in laying position, call bell in reach, side rails up x2, instructed to ring call bell if pain worsens. Reported to M.Fisher, RN-------------LSterner, SPN

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HEAS 1000

Date

Time

Nurse’s Notes

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HEAS 1000

Jarvis, C. (2019). Physical examination & health assessment (3rd Canadian ed.). Toronto, ON: Saunders Elsevier. Retrieved from: http://studywithclpna.com/nursingdocumentation101/

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