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Discussion

Need assessment tips PLEASE!!

Hi! Could anyone give me any basic advise on writing up a head to toe assessment please? This will be my first one, and I just want to learn what order it should be documented in, etc., and any advise or tips that anyone might have to offer.

Thanks for your time~ I appreciate any and all the help I can get.

God Bless!

Barb :nurse:

Featured Replies

Head to toe:

Look first,

Auscultate next,

THen Feel.

-:uhoh3:

hi,

aren't head to toe's fun? :p

here is a general list of things to include:

always think about what your patient's diagnosis is when you are writing up your assessment. this will tell you what is more important to focus on.

ex. your patient is on the telemetry unit and hooked up to a cardiac monitor. you will want to say specifially what his HR and rhythm are, what his heart sounded like (S1, S2, murmurs, irreg, reg, etc.) when you do cardiovascular.

here is a basic form i follow:

CNS--LOC, orientation, pupil reactions, appropriate speech/listening/sight

Cardio--HRR, cap. refill, skin temp, color

Repiratory--lung sounds, SOB with/without exertion, cough mucus/no mucus

Skin--general appearance, wounds, intact/not intact, hair, mucus membranes

GI/GU--abd(inspect, BT, percussion, palpation), urine/fecal output(amt, characterisics), drainage from member/lady parts, appearance

MSK/Pain--ROM, pain scale, reflexes

I&O--intake (what kind? PO, IV) output (urine, BM, blood)

Therapies/Meds--IV access, what kinds of fluids/meds

and make sure to include baseline vital signs, or any signs that changed following therapies, interventions, activity, meds, etc.

this is just a basic form...you will learn to add stuff as you go along.

HTH,

monica (5th quarter nursing student)

  • Expert

here are two links for you:

http://www.mededcenter.com/module_viewer.asp?module=+118#headtotoe - this is a great guide to physical assessment. it is called head to toe assessment in 5 minutes (well, maybe a little longer than that) that was originally posted on this thread https://allnurses.com/forums/f205/help-health-assessment-evals-139193.html by scmomof3.

http://md-do.org/files/physical/h&ptempl.doc - this is a template that lists the elements of the history and ros that should be addressed. it came from this site: http://md-do.org/files/physical/ . individual body system physical exams are listed here if you want to take the time to go through them. to get into these sites, you may be presented with a box to enter a passwork. you don't have to have a password to get into these files. just close that little box down. the file you pick will still download onto your computer.

I sent you a pm.:clown:

Head to toe:

Look first,

Auscultate next,

THen Feel.

-:uhoh3:

Our school uses the IPPA method.

Inspect (look):eek:

Percuss (finger-hammer taps):lol_hitti

Palpate (feel):icon_hug:

Auscultate (listen):heartbeat

Exception: Abdomen would follow your method.

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