Head-to-Toe Clinical Assessment Guide OmpathStudy

Head-to-Toe Assessment Guide Complete study document transcribed from all 6 source pages. This is an assessment guide, not a numbered question paper. The original page images remain attached for diagrams, tables and form layout. An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com Neurological Assessment Oriented to:  Person  Place  Time Communication/ Speech:  WNL  Non-verbal  Dysarthria  Aphasia:  Expressive  Receptive  Global Pupils:  PERRLA OR Equal:  Yes  No  R larger  L larger Round:  Yes  No  R abnormal shape  L abnormal shape Reactive to Light:  Yes  N Reaction:  Brisk  Sluggish  R no reaction  L no reaction Accommodation:  R  L (hold finger 4” above nose, bring closer to face, do both eyes maintain focus?) Glasgow Coma Scale (Score range 0 to 15, Coma =< 7) Eye opening to:  Spontaneous = 4  Verbal command = 3  Pain = 2  No response = 1 Verbal response to:  Oriented, converses = 5  Disoriented, converses = 4  Uses inappropriate words = 3  Incomprehensible sounds = 2  No response = 1 Motor response to:  Verbal command = 6  Localized pain = 5  Flexes and withdraws = 4  Flexes abnormally (decorticate) = 3  Extends abnormally (decerebrate) = 2  No response = 1 Location Muscle Tone Muscle Sensation Tremor Strength Head/ Neck  WNL  Flaccid  Spastic  WNL  To pain  No response to  No  Present pain R hand  WNL  Flaccid  Spastic L hand  WNL  Flaccid  Spastic RUE  WNL  Flaccid  Spastic LUE  WNL  Flaccid  Spastic RLE  WNL  Flaccid  Spastic LLE  WNL  Flaccid  Spastic Muscle Strength: 5 = WNL 4 = 75% normal 3 = 50% normal 2 = 25% normal 1 = 10% normal 0 = complete paralysis Respiratory Assessment Pulse ox:  WNL (95-100%)  WNL for this patient at Cough:  None  Non-productive, dry  Productive  Productive sounding, no sputum Sputum:  None Consistency:  Thick  Thin  Foamy Color:  White  Other, Oxygen:  N/A Room air  liters/ nasal cannula  % per face mask  Mechanical ventilator Respiratory rate:  WNL  Tachypnea/ hyperventilation (too fast)  Bradypneic/ hypoventilation (too slow/ shallow) Respiratory effort:  Relaxed and regular  Pursed lip breathing  Painful respiration  Labored  Dyspnea at rest  Dyspnea with minimal effort, talking, eating, repositioning in bed, etc.  Dyspnea with moderate exertion, dressing, walking =< 20 feet, etc.  Dyspnea when walking feet or with exercise Recovery time following dyspneic episode: minutes Respiratory rhythm:  WNL  Regular, tachypneic  Regular, bradypneic  Regular with periods of apnea  Regular pattern of increasing rate and depth, followed by decreasing rate and depth, followed by apnea (Cheyne-Stokes)  Regular, abnormal, rapid and deep respiration (central neurogenic hyperventilation)  Regular, abnormal, prolonged inspiration with a pause or sigh with periods of apnea (apneustic)  Irregularly irregular pattern/ depth (ataxic)  Irregular with periods of apnea (cluster breathing) Breath sounds (auscultate anterior & posterior, R & L upper, mid, lower chest):  Clear (vesicular) throughout  Decreased (atelectasis?)  Crackles:  Fine (sounds like hair rubbing)  Coarse/ moist  Gurgles/ rhonci (low pitched, moaning, snoring sounds)  Wheezes:  Inspiratory  Expiratory  Friction rub (sounds like leather rubbing against leather)  Absent (pneumothorax?) Upper chest: Right Left Mid chest: Right Left Lower chest: Right Left An Easy Guide to Head to Toe Assessment © Mary C. Vrtis, Ph.D., RN, 2008 available from www.aperiomlc.com 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 Peripheral Pulses Edema R radial  Yes  Doppler  No R hand/ arm  No  Non-pitting  Pitting + R femoral  Yes  Doppler  No R knee to thigh  No  Non-pitting  Pitting + R pedal  Yes  Doppler  No R ankle to knee  No  Non-pitting  Pitting + R post tib  Yes  Doppler  No R foot/ ankle  No  Non-pitting  Pitting + L radial  Yes  Doppler  No L hand/ arm  No  Non-pitting  Pitting + L femoral  Yes  Doppler  No L knee to thigh  No  Non-pitting  Pitting + L pedal  Yes  Doppler  No L ankle to knee  No  Non-pitting  Pitting + L post tib  Yes  Doppler  No L foot/ ankle  No  Non-pitting  Pitting + Sacrum  No  Non-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/ discom