nursing assessment

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Our class has to write a nursing assessment on a healthy client. Our instructor wants a head to toe assessment. I have mine done I just don't know if it's correct. Any suggestions would be greatly appreciated...

B/P 120/76

R 14

P 86

T 97.4 AX

Wt 151

Ht 5' 4"

pt is A & O x 3 no distress noted. skin is uniform and dry, apical heart rate loud and strong with no irregularity. Resp normal with no difficulty noted and no abnormal sounds detected. Abd flat with normal BS present in all 4 quads with no tenderness observed. full mobility in all extremeties with a cap refill time

and in the actual summary i've used the appropriate abbrev.

Does this read normal or is there some other things that need to be noted or phrased differently???

Thanks :lol2:

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Specializes in Geriatrics.

Any c/o of pain? 1-10?

Edit- saw no distress noted. I always state no c/o pain, 0 on scale 0-10.. just to be really specific.

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Specializes in Geriatrics.

are PERRLA?

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quess i forgot the no c/o of pain due to the fact we did our assessments on a a fellow classmate... and the PERRLA we did do but I have no idea how to document it.. I know this sounds crazy but our instructor is strictly a book reader only.. NO EXAMPLES.... I have no idea what i would do without this site and google.... except prob fail the class.... So in advance all help is appreciated... thanks for the advice.....i so need all i can get...

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Specializes in Geriatrics.

And you didn't state hand grasps or pedal pushes either.

Here is a link to a really good site. You click on the person and it gives you information, then you practice writing an assessment and can compare it to a 100% correct assessment afterwards.

http://freenursetutor.com/menuparent-assessment-nursing-process-charting/assessment-normal-female-assessment.html

You will love this site!

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Specializes in Geriatrics.
quess i forgot the no c/o of pain due to the fact we did our assessments on a a fellow classmate... and the PERRLA we did do but I have no idea how to document it.. I know this sounds crazy but our instructor is strictly a book reader only.. NO EXAMPLES.... I have no idea what i would do without this site and google.... except prob fail the class.... So in advance all help is appreciated... thanks for the advice.....i so need all i can get...

When documenting PERRLA... just write "A&Ox3, PERRLA," and then continue on with the rest from there. Basically that just say's "Alert and Oriented x3, Pupils equal, round and reactive to light and accomodations".

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OMG I LOVE THIS WEBSITE.... ALL YOU NURSES ARE SO HELPFULL.... thank you so much!!!

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Specializes in Geriatrics.

And that is so silly that your teacher doesn't give you examples. My teacher gave us a clear outline to look off of when writing assessments. It obviously is good to have everthing memorized.. but as a student and new nurse... you aren't going to remember everything. And that's okay.. because when you're out in the hospital working as a nurse.. you don't have to have it memorized (although you should strive to). There is nothing wrong with having a check off list in your pocket to make sure you are checking everything.

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Specializes in Geriatrics.

My suggestions is to make a check off list to look off of until you get the hang of assessments. I wish I could find the one I used in school to show you. Your teacher will be able to catch anything else you missed.. but I think you have everything once you add what I suggested and last BM (just noticed that too lol).

Just remember, every teacher is different. I was taught to write it one way in Q2 and another way in Q4. It's very subjective how you write it and teachers will most likely always comment how you can write something differently.. as long as you have everything written down, you're doing good.

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ok updated assessment... hope this is better...

A & O x3, no c/o pain, 0 on 0 -10 scale. moves all extremeties with equal strength. Resp even & unlabored, Apical heart rate strong with no abnormalities observed. Lungs clear Ant. and Post. Abd flat, soft and nontender. BS normal x 4 quads. LBM in A.M. Void clear, yellow without difficulty or pain. Cap refill

and yes i love that nursetutor site... that woulda come in very helpful during A&P.....Everybody in my class will have that website tomorrow....:yeah:

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Specializes in Geriatrics.

A & O x3, no c/o pain, 0 on 0 -10 scale. moves all extremeties with equal strength. Resp even & unlabored, Apical heart rate strong with no abnormalities observed. Lungs clear Ant. and Post. Abd flat, soft and nontender. BS normal x 4 quads. LBM in A.M. Void clear, yellow without difficulty or pain. Cap refill

That is a little better.

0800 Vitals: HR 87, RR 12, T 98.6, BP 120/80.

A&Ox3, no c/o of pain, 0 out of 0-10, ten being worst pain experienced. Speech is clear, PERRLA. Skin warm, clean, intact, dry and mucousa pink. Moves all extremities with equal strength. Hand graps are equal and strong bilaterally. Lung sounds clear. Respirations even and unlabored. Heart sounds clear and regular. Bowel sounds active in all 4 quads, abd flat, soft, and non-tender to palpation. Last BM 10/10/2010, brown, soft formed. Urine clear yellow with out difficulty or pain. Pedal pulses +3 bilaterally. Cap refill

That's how I write out my assessments. I didn't know how else to tell you how to fix certain things with out showing you, so I hope that's okay. I know some would say "Don't do work for other people", but I promise that's not what I was trying to do. :)

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Specializes in Geriatrics.

Oh! I found something else you'll probably like!

Head-to-Toe Assessment - Page 3- Nursing for Nurses

Scroll down to knittwhit's comment. She has attached a head-to-toe assessment pocket card. You can print that out and keep it in your pocket to use! :)

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