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Tuesday, January 13, 2015

Complete Head to Toe Assessment



Here's a quick reference table to try to help understand what should be assessed under each body system.


This isn't an end all be all list. There's a lot of things that could be added or deleted. Different units will be focused more on certain things than others. That's fine. I've been working on an ICU lately, so there are some things on here that would most likely only show up on one of those units such as ventilator settings. 

System
Usual Assessment
Additional Assessments
Neuro
Level of consciousness, orientation, motor ability, strength, ROM, speech, pupillary reaction to light, color and condition of the sclerea, temporal pulses, headache, vision, hearing, paresthesias, reflexes, intensity and perception to pain
Restraints, cervical collar, traction, surgical dressing, ICP monitoring device, level of sedation, PCA device
Cardio
Pulses, capillary refill, edema, heart sounds, murmurs, thrills, neck veins, PMI, ECG, arrhythmias, chest pain, activity tolerance
vascular access, cardiac output, pressure monitoring, pacemaker, compression stockings/device
Resp
Pulse oximeter, depth, rate, rhythm, use of accessory muscles, cyanosis, sputum- color/amount, cough, wheezes, stridor, position of trachea, suctioning tolerance
Supplemental O2, artificial airway size/position, mechanical ventilator settings, pleural chest tube, apnea monitor
GI/GU and Renal
Abdominal pain/ tenderness, guarding, distention, tolerance to eating/feeding, nutritional status, character of vomit/stool, nausea/vomiting, bowel sounds, urine amount/quality, foley status
Feeding tube type/ size/ location, feeding formula/rate, GI tubes patency/ drainage, surgical dressings
Skin
Color, texture, turgor, temperature, rashes, abrasions, wounds, burns, bruises, inflammations, itching, burning
Type of bed, patient's tolerance of bed, decubitus dressing, protective aids
Extremities
Limitations in movement, deformities, contractures, signs of ischemia: pain, pallor, paresthesia, paralysis, pulselessness, cold
Traction: weight, status, alignment, patient tolerance, pin site. Casts, splints, restraints, compression device
Psych
Emotional state, support systems, communication, coping ability, sleep/rest status
Patient/family teaching needs, social service needs, transfer/discharge planning

I hope this helps! Let me know if you have any questions in the comment section below, or shoot me an email. 

Xoxo,

Nightingale

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