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Student Resources: Narrative Head-to-Toe Assessment

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Head-to-toe Narrative Assessment.

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

What is included in a head to toe assessment?

Student Resources: Narrative Head-to-Toe Assessment

This 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.

Quote
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

Excellent resources concerning nursing documentation:

Practice Standard: Nursing Documentation

Ladies & Gentlemen of the jury, I present... the nursing documentation

Do's and Don'ts of Documentation

Documentation: Proactive Prevention of Litigation

8 Common Charting Mistakes To Avoid

Abbreviations: A Shortcut to Disaster

Narrative Assessment Form.doc

VickyRN, PhD, RN, is a certified nurse educator (NLN) and certified gerontology nurse (ANCC). Her research interests include: the special health and social needs of the vulnerable older adult population; registered nurse staffing and resident outcomes in intermediate care nursing facilities; and, innovations in avoiding institutionalization of frail elderly clients by providing long-term care services and supports in the community. She is a Professor in a large baccalaureate nursing program in North Carolina.

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13 Comment(s)

kristikkc

Specializes in ccu, med surg, ltc, home health. Has 4 years experience.

Thank you so much for the tips. Even those of us with nursing experience should go over pointers and webpages that help us with out charting.:yeah:

Tina1968

Specializes in OrthoRehab/Med-Surg. Has 2 years experience.

I am a first semester nursing student and this is really helpful, thank you!!

VickyRN, MSN, DNP, RN

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

Tina1968 said:
I am a first semester nursing student and this is really helpful, thank you!!

Glad this was helpful to you. Best wishes to you in nursing school 🙂

Dorali, BSN, LPN, RN

Specializes in 6 yrs LTC, 1 yr MedSurg, Wound Care. Has 12 years experience.

Quote
Hand grips unequal: strong on left, weak on right.

I'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!

Dondie

VickyRN, MSN, DNP, RN

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

Dondie said:
I'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!

Dondie

Hi Dondie and welcome :welcome:

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.

Savvy20RN, BSN, RN

Specializes in Med surg, Public Health. Has 7 years experience.

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

VickyRN, MSN, DNP, RN

Specializes in Gerontological, cardiac, med-surg, peds. Has 16 years experience.

savvy20 said:
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

Glad this has been helpful to you 🙂 It is amazing how fast you "grow" once in school.

The A on PERRLA means the ability to accommodate. Only people who can follow commands can do so. Otherwise, it is PERRL (for toddlers or confused adults).

MelodyNelson, LVN

Specializes in corrections. Has 13 years experience.

Thank you so much!!! Great resources!

Pink Magnolia, BSN, RN

Specializes in LAD.

I know this thread is old, but I'm so glad I came across it! I love the first website!