NUR 112 - Baseline Head to Toe.txt

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Author:
TomWruble
ID:
143887
Filename:
NUR 112 - Baseline Head to Toe.txt
Updated:
2013-03-17 12:42:19
Tags:
head toe assessment clinical nur112 keynursing
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Description:
Baseline Head to Toe Assessment Checklist
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  1. General
    Level of consciousness: alert, sedate, unconcious

    Orientation: person, place and time (AAOx3)

    Affect: afraid, irritable, distressed, attentive, ashamed, sad, happy, confident, shy, sleepy,  calm

    Skin color:

    Obvious distress:

    Ease of respirations and use of accessory muscles.

    Observe skin throughout assessment.
  2. Vital Signs
    • Temp
    • → Normal oral, resting: 37/98.6
    • → Range: 35.8 - 37.3 or 96.4 - 99.1
    • → 15 after hot/cold, 2 after smoke

    • Pulse
    • → Normal resting 50-90 BPM

    • Respirations
    • → 10-20

    • BP
    • → 120/80

    Sa02:
  3. Pain
    • Assess
    • location,
    • quality,
    • severity (0-10 scale),
    • radiation,
    • duration,
    • precipitating and alleviating factors,
    • associated symptoms,
    • level of sedation.
  4. Primary Symptom
    Assess client�s chief complaint and progress since hospitalization.
  5. Head & Neck
    • Check pupils for equality and reaction to light. (PERRL)
    • Check oral mucosa for color and moisture.
    • Observe for facial symmetry and tracheal deviation.
    • Check for neck vein distention at 45 degrees.
  6. Chest
    • Auscultate S1 and S2 at aortic, pulmonic, tricuspid and mitral areas for rate and rhythm and location of extra sounds.
    • Listen at apex for full minute.
    • Auscultate anterior and lateral lung sounds.
  7. Abdomen
    • Auscultate all quadrants for bowel sounds.
    • Palpate for distention of bladder and abdominal tenderness.
    • Ask about last BM, problems with urinating.
  8. Upper Extremities
    • Inspect arms.
    • Palpate radial pulses bilaterally and capillary refill;
    • assess grip strength and equality.
  9. Lower Extremities
    • Inspect legs.
    • Palpate dorsalis pedis pulses bilaterally.
    • Palpate legs and feet for edema.
    • 0: none
    • +1: slight pitting
    • +2: Deeper, countours still present
    • +3: Deep pittin, mpuffy appearance
    • +4: Deep persistent pitting, frankly swollen
    • Check foot presses.
    • Check feet for resistance.
    • Observe feet for lesions.
  10. Back
    • Turn to side or sit up;
    • auscultate posterior lung fields.
    • Observe skin on back and coccyx.
    • Palpate for sacral edema.
  11. Tubes and Equipment
    • Check all tubes from origin to insertion.
    • Verify correct oxygen flow,
    • correct IV solutions and flow rates.
    • Verify Foley draining and other equipment functioning appropriately.
    • Check dressings if present.

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