Ok- here is my head 2 toe card. Pardon any spelling
errors, it's been a long night! It was made specific for med-surg, but can be adapted to any area (I used the same one, specified to OB). Imagine a stick figure (I actually have one in the corner...), from head 2 toe:
In parenthases-I used prompters for the specifics.
Orientation (to person,place and time)
Neuro check, if applicable
Skin-color (pale/ pink/ruddy)
*Any O2, NG tubes would go here
rhythm (regular/irregular or normal/abnormal)
*Chest tubes would go here
Upper extremities- If IV present, note the solution, the rate and the site. Note the site for warmth, redness,edema etc.
listen (BOSO present x 4 quads?Rhythm of BOSO-normal/hyper/hypoactive and the intensity-high/low-pitched)
*Any PEG,PEJ,etc. tubes would go here.
Bowel and Bladder- voiding (color, clarity,amount)
Foley? (patent, note drainage system)
Ostomy? (note stoma)
*This would include any suprapubic caths,drains,etc.
Homan's sign (negative/positive)
Pedal pulses (+1=weak/faint, +2 palpitable, +3 bonding)
Capillary refill (brisk/sluggish-how long if >3 seconds)
**We were taught to put any dressings or wounds in the order they came. For example, a forarm dressing would go with the upper extremities. A cast would include a circ check with the corresponding area. Edema include pitting (and the deepth) or nonpitting at the correspodning area.
I hope this helps. I don't know if it was specific to my school or not-but I still use it today to find a problem area. It's great for focusing in on a specific problem. For us- we further went on, later in the day to assess activity, I & O, etc. It takes practice to be able to do it in 15 minutes-but it comes so automatic after awhile that you start it as soon as you walk in a room.
On that note- I'm off to bed. Have a great day everyone.