Writing a head to toe assessment
Grips unequal, strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. Skin is free of lesions and appears rugated and darkly pigmented. No bruits auscultated over carotids. No slurring of speech.
Head to toe assessment ppt
Trachea in midline. Neck: The neck muscles are equal in size. There are also no signs of infection and infestation observed. C7 is visible and palpable with neck flexion. Breath sounds clear to auscultation throughout all lung fields. Thyroid gland nonvisible but palpable when swallowing. The client manifested quiet, rhythmic and effortless respirations. Patient position prior to standing Asymmetry may indicate cardiovascular conditions or post-surgical complications. Normal distribution of hair on scalp and perineum. Respirations even, unlabored.
Hair: The hair of the client is thick, silky hair is evenly distributed and has a variable amount of body hair. Colour should return to the nail instantly or in less than 3 seconds.
To prevent those kind of scenarios, we have created a cheat sheet that you can print and use to guide you throughout the first step of the nursing process. The client showed coordinated, smooth head movement with no discomfort. Neck symmetric with centered head position and no bulging masses.
Nails form degree angle at base, are hard, smooth, and immobile. No malodorous discharge noted from vagina.
The spine is vertically aligned.
There is no edema or tearing of the lacrimal gland. Verbalized understanding.
Head to toe assessment script
Eyes and Vision Eyebrows: Hair is evenly distributed. Tonsillar pillars pink and symmetric. Eyelashes: Eyelashes appeared to be equally distributed and curled slightly outward. Tactile fremitus symmetric. VS When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. Apical pulse regular rate and rhythm; s1, s2 noted. Full smooth ROM against gravity and resistance. Clubbing of nails, in which the nails present as straightened out to degrees, with the nail base feeling spongy, occurs with heart disease, emphysema, and chronic bronchitis. With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation. CWMS: colour, warmth, movement, and sensation of the hands and feet should be checked and compared to determine adequacy of perfusion. Abdomen is flat and symmetric with no bulges or lumps. Circumcised penis is free of rashes, lesions, and lumps and is soft, flaccid and nontender on palpation. Homans sign negative bilateral.
based on 118 review