Help with Head to Toe

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I need help writing a head to toe assessment. I don't know where to start, Help! Any examples would be great Thanks

I've tried looking on here but i can't find any examples

Tait, MSN, RN

2,140 Posts

Specializes in Acute Care Cardiac, Education, Prof Practice.

Start at the head! :)

Think about all the things you look for on the head. Mostly neurological right?

Then move down neck (lymph nodes, swallow etc)

Chest: Lungs, heart, trunk shape etc.

Tait

CarsonsMommy

30 Posts

Thanks

First time on med-surg and first time writing a head to toe. We did a check off in school about 3 months ago, and haven't done one since, i'm sorta lost!

Assessments, along with any skill in nursing, takes practice to get it right. Assessing might feel kind of "weird" at first but as you keep doing them you'll start to get a "feel" for them and they will become easier.

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

someone over on the general nursing discussion forum posted a head-to-toe assessment website that also includes several videos of a nurse doing assessments. i added it to the head-to-toe assessment list on the assessment sticky. if you want to see these videos and the assessment information go here: http://nursingcrib.com/physical-assessment/

CarsonsMommy

30 Posts

Thanks for the reply, I know how to do it, just not write it out in nursing format, i've never seen it written before.

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

Oh, I thought there were one or two examples of this on the assessment or documentation stickies. Did you find them? I'm sure I just saw it last week.

CarsonsMommy

30 Posts

Thanks :bowingpur, I didn't even check there!!!:smackingf

Daytonite, BSN, RN

1 Article; 14,603 Posts

Specializes in med/surg, telemetry, IV therapy, mgmt.

this is on post #19 9f this sticky: https://allnurses.com/nursing-student-assistance/nursing-documentation-168921.html - nursing documentation. it was posted by vickyrn. i knew i had seen this!

here is a head-to-toe narrative charting template that i developed for my first semester
rn
students last semester:

2/12/2007 0800. 86 y.o. male admitted 2/1/07 for left cva. vs 37.4° c, hr 97, rr 22, bp 140/76. alert and oriented x 4; 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 right, weak on left. left arm has limited mobility due to weakness secondary to cva. has a 20 gauge saline lock to right 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 right hand. instructed to call for any needs or to request assistance before attempting to get up. verbalized understanding. side rails up x 3. will continue to monitor closely.............................. s.johnson, sn, *****

CarsonsMommy

30 Posts

Thanks so much! your a great help:bow::)

Specializes in LTC.

In school when they have us do Nurses Notes, I basically follow the assessment sheet they gave us.

Date and Time-- Position received in. Appearance/Skin. Vital Signs. Pain. Orientation. Mental Status. Sensory/Motor. Lung Sounds. Cough. SpO2. Pulses. Edema/Cyanosis. Bowel Sounds. Abd Palpation/Appearance. BM/Flatus. Diet. Urine. Foley?. IV.(Infusing as ordered). Mobility. What is being ordered( ex.. Awaiting transfer to radiology for CT scan) and/or will continue to monitor.

I add stuff as needed but thats usually the outline I follow when we have to do nurses notes during class and clinical.

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