Narrative head to toe assessment HEAD TO TOE NARRATIVE CHARTING :…

Question Narrative head to toe assessment HEAD TO TOE NARRATIVE CHARTING :… Narrative head to toe assessment HEAD TO TOE NARRATIVE CHARTING:·        Time:   Report received from………..·        Vital signs: T, P, R, B/P, O2 Sat. ·        Neuro: AAO x _3__ (appropriate since this is traditionally understood to be person, place, and time) or specify any neurological deficits such as confused to time, etc. If using AAO x 4 document – Awake, alert, and oriented to person, place, time, and situation. ·        Skin:  (General comments) warm, dry, moist, hot, flushed, pallor or pale. – specific skin assessment addressed when areas encountered on head to toe assessment ·        Respiration: regular / irregular, deep / shallow, labored / unlabored, Chest clear or with adventitious sounds (wheezes, rales, ronchi) and where – (bilaterally, upper lobes, lower lobes RUL, RLL, LUL, LLL) Oxygen (flow, concentration, delivery method) – BNC 02 @ 2 lpm.- trach – ETT – Suction information (color consistency, etc – Other devices with locations, and other related info – (Chest tubes – l lateral chest 5th IC space, dressing intact, connected to Atrium with 20cm water seal, no suction or indicate amount of suction – no air leak or presence of air leak , no crepitus or presence noted at entry site. ·        Cardiac: (Cardiac monitor = CM → NSR (normal sinus rhythm – etc) @ 68. (heart tones = HT – audible, faint, etc, w/o murmur, gallop or rub m/g/r) ·        Abdomen: (soft / firm, tender / nontender, distended / nondistended. Bowel sounds absent or hypo, normo, or hyperactive if present and x 4 quads or specify RUQ, LUQ, LLQ, RLQ). Dressing – location, intact, describe drainage if present. Wound, suture line, staple line or ostomy location and description of site and drainage if present·        GU: voiding or catheter (size of catheter), nature of urine – color, clarity, amount (scant, moderate, large) collecting to bedside bag (BSB), Drainage at urinary meatus or suprapubic area if suprapubic catheter in place. ·        Extremities: Actively MAE (moves all extremities) or describe deficits (ex. left hemiparesis) Pulses palpable & strong bilaterally (means to all extremities or can gauge pulses 1+ – 4+ in specific extremities as needed) Any contractures? Any edema (& gauge 1+ – 3+ – pitting or non-pitting) ·        Comfort: No c/o pain or describe on pain scale 0-10, describe discomfort & location in patient’s words (quotation marks for patient statements” – measures taken to relieve pain and re-evaluation of pain on 0-10 scale?) ·        Family/visitors/ancillary personnel or Dr Visits: Family at bedside (BS), Dr ___________, in room with patient (chart time of visit) transported to X-ray, returned to room from X-ray, surgery etc (chart time of departure and return to room) ·        Accucheck: Time, result ______ug/dl, type, amount of insulin given, and injection site, Document any signs/symptoms of hypo/hyperglycemia noted. ·        Environment: Elevation of head of bed (HOB) Call light within reach, Position of the bed from the floor (High or low)? Side rails up or down? Bed type if specialty bed – bariatric, lo-boy bed etc.·        Hygiene: AM or PM care provided, Linen changed, and how patient tolerated any interventions provided. **  Any interventions provided or equipment in use should be entered in the appropriate areas based on a head to toe assessment – (EX – if a central line is in place in the neck or subclavicular area – it would logically be addressed in the initial assessment when that area is being assessed – such as following the general skin assessment (warm & dry (W/D) which would be noted during the taking of the initial vital signs because you can tell the temperature and moisture of the skin when taking a pulse (apical or radial).  ** A logical way to address the IV should be from the farthest point away from the patient   progressing to the patient (EX – IV D5 ½ NS infusing at 125ml/hr via Baxter controller to               the R. Subclavian site per a 20 gauge intracath. Transparent dsg. intact to site w/o redness             or edema noted.             Health Science Science Nursing NURS 478 Share QuestionEmailCopy link Comments (0)