Student Resources: Narrative Head-to-Toe Assessment
- 20Sep 27, '09 by VickyRN Senior Moderatorthis is an example of a head-to-toe narrative assessment note. i have my first semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.
10/05/2009 0800. 86 y.o. male admitted 10/01/09 for left-sided cva with right-sided hemiparesis. vs 37.4° c, hr 97, rr 22, bp 140/76. alert and oriented to person, place, day/ time, and situation; denies any pain or distress. perrla. responds appropriately to verbal stimuli; no slurring of speech. at risk for aspiration related to dysphagia; on thickened dysphagia diet. feeds self with assistance. skin acyanotic with loose turgor. mucous membranes moist and pink. negative jvd. respirations even, unlabored. breath sounds clear to auscultation throughout all lung fields. (if your patient is on o2, make sure you record the o2 rate and delivery system here, along with pulse ox readings). apical pulse regular rate and rhythm; s1, s2 noted. abdomen soft & nondistended with bowel sounds active in all 4 quadrants. pink nailbeds with capillary refill less than 2 seconds in all extremities. peripheral pulses palpable in all extremities. moves all extremities. hand grips unequal: strong on left, weak on right. right arm has limited mobility due to weakness secondary to cva. has a 20 gauge saline lock to left lateral forearm. site is free from redness or drainage, with tegaderm dressing intact. (if your patient has an infusing iv, make sure you record the fluid and rate in your assessment). uses urinal, has occasional episodes of incontinence. urine clear yellow. no skin breakdown noted. ted hose on bilaterally. homan’s sign negative bilaterally. feet cool, dry, intact, with thick toenails bilaterally. side rails up x 3, bed in low position. call bell within easy reach of left hand. instructed to call for any needs or to request assistance before attempting to get up. verbalized understanding. will continue to monitor closely. ……………………………….. s.johnson, student nurse
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abbreviations: a shortcut to disasterLast edit by VickyRN on Oct 1, '09
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- 0Oct 8, '09 by DondieHand grips unequal: strong on left, weak on right.
I'm just curious. Thanks!
- 1Oct 9, '09 by VickyRN Senior ModeratorQuote from DondieHi Dondie and welcomeI'm a new CNA so I don't know much about assessments, but this part caught my attention. Could you give me a brief explaination of what this represents? How do you check the grip, by having them squeeze your hands?
I'm just curious. Thanks!
Yes, you're on the right track You have the client squeeze your hands (both hands at the same time - only allow two fingers from each of your hands to be squeezed, to avoid being "crushed" by a very strong grip) and then let go. The client must be able to both grip and let go. Rate according to strength and equality of left and right.
- 0Oct 9, '09 by VickyRN Senior ModeratorQuote from savvy20Glad this has been helpful to you It is amazing how fast you "grow" once in school.Two months ago none of this would have made sense to me. I've learned so much since starting nursing school. -squeals- Thanks so much for this. We just started clinicals so this really helps. XD