Question Answered step-by-step please help me to check my head to toe assessment document and edit… please help me to check my head to toe assessment document and edit or proofreading if needs. Thank you Performed head to toe assessment with instructor in room 3A. Patient is a 65 y/o caucasian woman. Patient was AOx2, alert, speaking slurry. Head is appearance normal, no tenderness, no abrasions and no abnormalities. Hair is clean, moist, no infestation. Eyes PERRLA, no drainage, mucous membranes pink and moist, sclera is pinkish white. Ears symmetrical, no cerumen build up and no hearing aid. Nose is clear and symmetrical. Mouth is is moist, edentulous, and the tongue is pink in color. Lymph nodes non palpable. Chest is symmetrical, no scars or abrasions. Skin is warm to touch. Heart is clear, L breast had mastectomy, scar 15 cm(horizontally) R breast fold redness (erythema). Apical pulse 76bpm, regular. Lungs are clear, no wheezing or crackles. ROM on both upper extremities. Skin discoloration on R arm, 6cm width, 3cm length, blue/green color. Capillary refills R and L in less than 3 second. Skin discoloration on L arm, 1cm with, 03 length in purple color. Perineum intact, no redness, diaper is wet. No painful urination. Abdomen is soft, and non-tender, active bowel sound in all four quadrants. bowel incontinence. LLQ skin discoloration, abdominal fold redness, Bilateral groin redness. ROM lower extremities, strong strength. Back was free of lesions, the upper back has sunburn, lower back skin intact, warm to touch. No edema. Pedal pulses palpable, capillary refill within 3 seconds. Patient was able to f/u and tolerated assessment without difficulty. BP: 97/71 Pulse: 65 Temp: 97.7 RR: 20 O2Sat: 97% room air, 0/10 pain. Health Science Science Nursing LVN VN Share QuestionEmailCopy link Comments (0)
Question Answered step-by-step please help me to check my head to toe assessment document and edit… please help me to check my head to toe assessment document and edit or proofreading if needs. Thank you Performed head to toe assessment with instructor in room 3A. Patient is a 65 y/o caucasian woman. Patient was AOx2, alert, speaking slurry. Head is appearance normal, no tenderness, no abrasions and no abnormalities. Hair is clean, moist, no infestation. Eyes PERRLA, no drainage, mucous membranes pink and moist, sclera is pinkish white. Ears symmetrical, no cerumen build up and no hearing aid. Nose is clear and symmetrical. Mouth is is moist, edentulous, and the tongue is pink in color. Lymph nodes non palpable. Chest is symmetrical, no scars or abrasions. Skin is warm to touch. Heart is clear, L breast had mastectomy, scar 15 cm(horizontally) R breast fold redness (erythema). Apical pulse 76bpm, regular. Lungs are clear, no wheezing or crackles. ROM on both upper extremities. Skin discoloration on R arm, 6cm width, 3cm length, blue/green color. Capillary refills R and L in less than 3 second. Skin discoloration on L arm, 1cm with, 03 length in purple color. Perineum intact, no redness, diaper is wet. No painful urination. Abdomen is soft, and non-tender, active bowel sound in all four quadrants. bowel incontinence. LLQ skin discoloration, abdominal fold redness, Bilateral groin redness. ROM lower extremities, strong strength. Back was free of lesions, the upper back has sunburn, lower back skin intact, warm to touch. No edema. Pedal pulses palpable, capillary refill within 3 seconds. Patient was able to f/u and tolerated assessment without difficulty. BP: 97/71 Pulse: 65 Temp: 97.7 RR: 20 O2Sat: 97% room air, 0/10 pain. Health Science Science Nursing LVN VN Share QuestionEmailCopy link Comments (0)
