An_Easy_Guide_to_Head_to_Toe_Assessment_Vrtis_12_2008_Website

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Unformatted text preview: __ Nutritional intake: Adequate Inadequate, address in care planning Bowel sounds (all four quadrants): Active, WNL Hyperactive Hypoactive Absent (listen for 5 full minutes) Tubes: None Salem sump Nasoduodenal feeding tube PEG tube Jejunostomy (J) tube pH aspirate: ___ Insertion site: WNL Pressure areas Redness Purulent drainage Tenderness Warmth Tube feeding: Type: ________________ Amount: ____ mls over ____ hours via Gravity Pump Intermittent Continuous (keep head of bed elevated to prevent aspiration, check placement – pH should be 0 to 4) Stoma: N/A Colostomy Ileostomy (Notify the surgeon of all abnormalities observed for new colostomies) Stoma status: Pink, viable Red Deep red Dusky Dark Retracted below skin S/S of infection PEG tube = percutaneous endoscopic gastrostomy tube Skin Integrity Assessment Skin color: WNL Pale Jaundice Dusky Cyanotic Skin is: Intact No, see below No, describe: ___________ Braden Scale Score: _______ Signs/ symptoms of inflammation/ infection: Redness Tenderness/ pain Warmth Swelling Location(s): Contusion(s)/ Ecchymosis: N/A Size: Length _____ cm Width _____ cm Depth _____ cm Location(s): ____________________ Client’s explanation of bruising: _________________________________________ Location Type Abrasion Avulsion Burn Laceration Puncture Pressure ulcer, Stage _________ Stasis ulcer Surgical incision, closed, edges are approximated Surgical, open areas total wound dehisence ______________ Wounds Tunneling Size Length ____ cm Width ____ cm Depth ____ cm Incision length ___________ cm None None Surrounding Tissue WNL Present at _____ o’clock, depth ______ cm Present, surrounding tissue is: Dusky Soft Boggy Fluid-full Other, describe: Redness Tenderness Pain Warmth Streaking Excoriation Bruising Discolored Dusky Present at _____ o’clock, depth ______ cm _______ # of staples/ sutures (circle one) Is client on a pressure reduction or relief surface: No Undermining Wound edges WNL Hyperkeratotic Drainage Color/ Characteristics: Serous Serosanguinous Bloody Yellow Tan Brown Green Purulent? No Yes Odor? No Yes Yes, type: __________________________________________ *Undermining is due to liquefication of necrotic tissue or mechanical forces that sheared and separated underlying tissues. An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com Pain Assessment Location of pain: __________________________________ Pain is: Acute Chronic Constant Intermittent Pain is affecting: N/A Sleep Activity Exercises Relationships Emotions Concentration Appetite Other: __________________________________________________________________________________ Description of pain: Sharp Stabbing Throbbing Shooting Burning Electric-shock like Pain rating on a scale of 0 to 10: ______ Acceptable level of pain for this client: ________ Highest pain level today: _______ Best pain level today: _______ Best pain ever gets: _______ What makes the pain worse? Activity Exercises Other: ______________________________________________ What makes the pain decrease? Rest/ sleep Medication Heat Cold Family presence Music Reading Distraction Meditation Guided imagery Relaxation techniques Other: _______________ Opiod medication(s): __________________________________________________ Route: _____ Last dose: ____________ Breakthrough medication(s): ___...
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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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