Nurses General Nursing
Published Sep 7
Emart
7 Posts
I'm sharing these examples of a head to toe assessment with negative and positive findings. Please post any suggestions on what you think is important to add.
NEGATIVE FINDINGS
General Appearance
• Observation: The patient appears alert, oriented, and well-nourished, sitting comfortably with a relaxed posture and good eye contact. No signs of distress.
Head and Face
• Skull and Scalp: Normocephalic and atraumatic. Scalp is clean and free of lesions.
• Facial Symmetry: Symmetrical facial movements with no drooping or abnormalities.
• Eyes: Pupils are equal, round, and reactive to light and accommodation (PERRLA). Sclera is white, and conjunctiva is pink and moist.
• Ears: External ears are symmetrical and free of lesions. Ear canals are clear with no discharge; tympanic membranes are intact and pearly gray. Hearing is intact bilaterally.
• Nose: Nasal passages are patent without septal deviation; mucosa is pink and moist. No sinus tenderness on palpation.
Mouth and Throat
• Lips: Pink, moist, and free of lesions.
• Oral Mucosa: Pink, moist, and intact with no lesions. Tongue is midline and well-papillated. No signs of thrush.
• Teeth and Gums: Teeth are in good repair; gums are pink and firm without swelling or bleeding.
• Pharynx: Pharynx is clear, with no erythema, swelling, or exudates. Tonsils are not enlarged.
Neck
• Trachea: Midline with no visible swelling.
• Thyroid: Non-palpable and without enlargement or nodules.
• Lymph Nodes: No cervical lymphadenopathy; lymph nodes are non-tender and not palpable.
Respiratory System
• Inspection: Symmetrical chest expansion with normal respiratory effort; no use of accessory muscles.
• Auscultation: Clear breath sounds bilaterally in all lung fields without wheezes, crackles, or rhonchi.
• Percussion: Resonant throughout lung fields.
• Palpation: No tenderness or masses.
Cardiovascular System
• Auscultation: Regular rate and rhythm (RRR) with no murmurs, gallops, or rubs.
• Peripheral Pulses: 2+ (normal) in all extremities bilaterally; no carotid bruits.
• Edema: No peripheral edema.
Abdomen
• Inspection: Flat and symmetrical with no visible masses or lesions.
• Auscultation: Normoactive bowel sounds in all four quadrants.
• Percussion: Tympanic throughout with no areas of dullness.
• Palpation: Soft, non-tender, and without organomegaly or masses.
Musculoskeletal System
• Inspection: Normal curvature of the spine; no swelling, redness, or deformities in joints.
• Palpation: No tenderness over the spine or joints.
• Range of Motion (ROM): Full ROM in all extremities without pain or crepitus.
Neurological System
• Mental Status: Alert and oriented to person, place, and time. Speech is clear and coherent.
• Motor Function: 5/5 muscle strength bilaterally in upper and lower extremities.
• Reflexes: 2+ reflexes bilaterally and symmetrical. No clonus.
• Cranial Nerves: Cranial nerves II-XII are intact.
Skin
• Inspection: Skin is warm, dry, and intact with uniform color. No rashes, lesions, or bruising.
• Temperature and Moisture: Normal temperature; skin is not excessively dry or moist.
• Wounds: No open wounds or signs of pressure ulcers.
POSITIVE FINDINGS
• Observation: The patient appears lethargic and disoriented, with slumped posture and minimal eye contact.
• Skull and Scalp: No visible lumps, lesions, or abnormalities.
• Facial Symmetry: Facial asymmetry noted; the left side of the face appears droopy.
• Eyes: Pupils are unequal (anisocoria); the left pupil is 4 mm and sluggish to light, while the right pupil is 3 mm and reactive.
• Eyelids: Slight ptosis of the left eyelid.
• Conjunctiva and Sclera: Conjunctiva is pale, suggesting possible anemia; sclera is yellowish, indicating jaundice.
• Ears: Mild erythema and discharge from the right ear canal; decreased hearing on the right side.
• Nose: Nasal congestion with a deviated septum to the right; slight tenderness on palpation of the maxillary sinuses.
• Lips: Dry and cracked, indicating dehydration.
• Oral Mucosa: Pale with white patches on the tongue and inner cheeks, suggestive of oral thrush.
• Teeth and Gums: Several dental caries noted; gums are red, swollen, and bleed upon light palpation.
• Pharynx: Erythema and swelling present; tonsils are enlarged with white exudates.
• Trachea: Midline but there is noticeable swelling on the right side of the neck.
• Thyroid: Enlarged, with palpable nodules.
• Lymph Nodes: Anterior cervical and submandibular lymph nodes are tender and enlarged.
• Inspection: Asymmetrical chest expansion noted on inspiration.
• Auscultation: Diminished breath sounds in the right lower lobe; crackles heard on both bases, suggestive of fluid accumulation.
• Percussion: Dullness over the right lower lung field.
• Palpation: Tenderness over the left upper anterior chest wall.
• Auscultation: Irregular heart rhythm; grade 3/6 systolic murmur heard at the left sternal border.
• Peripheral Pulses: Diminished dorsalis pedis and posterior tibial pulses bilaterally.
• Edema: Pitting edema observed in the bilateral lower extremities (2+).
• Inspection: Distended abdomen with visible veins.
• Auscultation: Hypoactive bowel sounds present in all four quadrants.
• Percussion: Tympany noted throughout with dullness in the flanks, suggestive of ascites.
• Palpation: Rebound tenderness in the right lower quadrant; positive Murphy's sign indicating possible cholecystitis.
• Inspection: Swelling and erythema noted in the right knee joint.
• Palpation: Tenderness over the lumbar spine.
• Range of Motion (ROM): Limited ROM in the right knee with pain on movement.
• Mental Status: Disoriented to time and place; speech is slurred.
• Motor Function: Weakness noted in the left upper and lower extremities (3/5 strength).
• Reflexes: Hyperreflexia in the right upper extremity.
• Cranial Nerves: Cranial nerve VII deficit (facial nerve) on the left side; drooping of the mouth.
• Inspection: Jaundice present; several bruises on the arms and legs at varying stages of healing.
• Temperature and Moisture: Skin is cool and clammy.
• Wounds: Pressure ulcer on the sacrum, stage 2.
JKL33
6,921 Posts
What is the context of this?
hppygr8ful, ASN, RN, EMT-I
4 Articles; 5,157 Posts
JKL33 said: What is the context of this?
I concur. Is this for school? Most head to toes I've done in practice as an RN allow you to chart by exception. I do psych now so mostly mental status and ambulation skills are stressed.
Hppy