nursing assessment

[crazyts]

Our class has to write a nursing assessment on a healthy client. Our instructor wants a head to toe assessment. I have mine done I just don't know if it's correct. Any suggestions would be greatly appreciated...

B/P 120/76

R 14

P 86

T 97.4 AX

Wt 151

Ht 5' 4"

pt is A & O x 3 no distress noted. skin is uniform and dry, apical heart rate loud and strong with no irregularity. Resp normal with no difficulty noted and no abnormal sounds detected. Abd flat with normal BS present in all 4 quads with no tenderness observed. full mobility in all extremeties with a cap refill time

and in the actual summary i've used the appropriate abbrev.

Does this read normal or is there some other things that need to be noted or phrased differently???

Thanks

[crazyts]

i in no way think you are doing my work for me..... I dont know who you are but i swear i could kiss you... and thanks for the link to the head to toe assessment, i had already found it and actually printed it off. Doing the assessment isn't where im having difficulty... its writing the summary.. I've been a cna for 2 years and doing cna summaries are so much different than these summaries.... I did the whole assessment on my classmate and the instructer was there and said we did the physical parts right, then she turned around and said " now write your assessments out" .. And that was the extent of her helping us. she went to her office and sit down.... Our book shows us nothing about writing one out.. I googled it and tried to find examples but all i could find was like patients in a hosp setting assessment. So i just figured I'd try here and see what i could find....Thank you so much... I have worked all weekend and tried finding these on my blackberry while at work with no luck..You my dear are a true nurse.....

[anonymous1919, LPN]

Thank you! You'll get the hang out it... they're really easy, it gets very repetitive! :)