Head to Toe Physical Assessment

Head to Toe Physical Assessment - Patient Initials/Room_...

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Nursing Care Plan NUR1022C Fundamentals – Spring, 2011 Head to Toe Physical Assessment Neurosensory Alert/Oriented: Person X Place X Time X Confused___ Sedated X Pupils: PERRLA X Equal X Unequal___ Reactive (Brisk)___(Sluggish) X Pupil Size: Left 4 mm Right 4 mm Prosthetic Devices: Glasses X Hearing Aids N/A Dentures N/A Other: N/A Integument Describe Skin Integrity (Intact, rashes, wounds, ecchymotic areas) The skin is warm, pale, dry, and intact with no evidence of rash, or decubitus ulcer. The skin recoil is within normal limits. He has a large ecchymosis in his left forearm that was a perioperative site of the IV. Her IV lines are patent, no evidence of infiltration or phlebitis. He has the 10 cm scar running vertically in the mid-abdomen. There are 20 staples present, and incision is covered with dry to dry dressing, changed daily . Hygiene: Self___ Assist___ Partial Assist X Skin Color: Pallor Skin Turgor: Non-elastic, tenting Nail Beds: pale, no evidence of clubbing Capillary Refill: 3 seconds
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Head to Toe Physical Assessment - Patient Initials/Room_...

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