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Unformatted text preview: ____________ Right ________________ Left ________________ An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from Cardiovascular Assessment Skin: Warm/ dry Cool Clammy/ diaphoretic Skin turgor: WNL Tenting Weight: ________ kg/ lb Capillary refill: WNL Delayed > 2 seconds Apical pulse rhythm: Regular Regularly irregular Irregularly irregular Apical pulse rate: Heart sounds: WNL (60-100) Normal S1S2 S3 (gallop) Bradycardia Valve click [artificial heart valve] Tachycardia Murmur: (Extremely low or high HRs Holosystolic decrease C.O., blood and O2 Midsystolic to the vital organs). Diastolic Apical/ radial deficit: No Yes R radial R femoral R pedal R post tib L radial L femoral L pedal L post tib Peripheral Pulses Yes Doppler Yes Doppler Yes Doppler Yes Doppler Yes Yes Yes Yes Doppler Doppler Doppler Doppler No No No No R hand/ arm R knee to thigh R ankle to knee R foot/ ankle No No No No Edema Non-pitting Non-pitting Non-pitting Non-pitting Pitting ___+ Pitting ___+ Pitting ___+ Pitting ___+ No No No No L hand/ arm L knee to thigh L ankle to knee L foot/ ankle Sacrum No No No No No Non-pitting Non-pitting Non-pitting Non-pitting Non-pitting Pitting ___+ Pitting ___+ Pitting ___+ Pitting ___+ Pitting ___+ ECG assessment if applicable, see below Genitourinary Assessment Genitalia: WNL Abnormalities, describe: ______________________________________________________________ Assessment of urination: WNL Burning Frequency Urgency Bladder distention Pelvic pain/ discomfort Lower back/ flank pain/ discomfort Continent: Yes Stress incontince with coughing, etc. Rarely incontinent Regularly incontinent Urine amount: WNL (over 30 mls/ hr, output approximates intake) Less than 30 mls/ hr (dehydration? Post-op volume depletion? SIADH?) Output greatly exceeds intake (Post-op diuresis? Diabetes insipidus?) Urine color: Yellow, WNL Amber Orange Dark amber Pink Red tinged Grossly bloody Urine characteristics: Clear, WNL Cloudy Sediment Abnormal odor Urostomy: N/A Urostomy/ ileal conduit Continence maintaining nipple valve ostomy Stoma status: Pink, viable Red Deep red Dusky Dark Retracted below skin S/S of infection Urinary stents: N/A R ureter L ureter Urinary catheter: N/A Foley, short term Foley, long term at home Suprapubic catheter Insertion site: WNL S/S of infection An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from Gastrointestinal Assessment Oral mucosa: Intact Moist Dry Pink Pale Tongue: WNL Pink White patches Abdomen: WNL Distended Taut Ascites Abdominal incision Abdominal girth (PRN): ____ cm Abdominal pain, see pain assessment Bowel movements: WNL Constipation Diarrhea Bowel program required Other, __________________ (if diarrhea, assess risk for C. diff or VRE) Last bowel movement: Today Yesterday Other, ____________________________________________________ Continent: Yes Rarely incontinent Regularly incontinent Nausea/ vomiting: No Yes, describe: ______________________________________________________________...
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This note was uploaded on 03/26/2013 for the course NURSING 1201 taught by Professor Smith during the Spring '12 term at Glendale Community College.

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