Head To Toe Assessment NRS 111

Student Name_____________________
Rock Valley College
MEDICAL - SURGICAL CLIENT ASSESSMENT

Fundamentals of Nursing Clinical - Walters
Initials_________
Age_______ Sex____ Marital Status___________ Room_______ Date___________
Diagnosis(s) ______________________________________________________________________________________
Pt's Major Concerns: _______________________________________________________________________________
Allergies:_________________________________________________________________________________________
Lab values last 24 hours or identify date drawn:__________________________________________________________
Hg_____Hct_____WBC_____Plt_____Na+_____K+_____ Electrolytes_____ BUN_____ Creatinine_____ Albumin____
LFTs____________ Coags______________ EKG___________________ Chest X-Ray___________________________
History:
VITAL SIGNS / BODY MEASUREMENTS: VS@_______time T_____ P_____ R_____ B/P_____ (L or R arm)
VS@______time T_____(ORAT) Pulse______Apical or R, Regular or Irregular Resp_____ Labored or Unlabored
B/P_______ Left_______ Right_______ Supine_______ Sitting_______ Standing_______
SpO2 (Pulse Oximetry)__________ on: Room Air or O2 @__________L/min per___________
Blood glucose monitoring (Time): _____________________ (Time)_____________________
Insulin Coverage:____________________________________________________________________________________
Height_______ Weight_______ in Wt_______lbs. Hearing Aide Y - N Glasses Y - N Walker Y - N Other:
NORMAL
Mental Status
Alert/oriented to person, place and time
Behavior appropriate to situation
Follows directions
Verbalization clear and understandable
Psychosocial / Spiritual Status
Reports no emotional / spiritual distress
Calm affect - Pleasant affect
Neurological Status
Pupils equal, reactive to light: brisk or sluggish
Size L_____mm R_____mm
Hand grasps equal and strong
Sensation intact to extremities (all 4)
Sclera of eyes: white
No drainage from eyes
Good visual acuity reported by client
No drainage from ears
No difficulty hearing as reported by client
Cardiovascular Status
Apical and radial pulse equal and regular, strong
Peripheral pulses palpable and equal 2+
No tachycardia (>100) or Bradycardia (<60)
Nail bed capillary refill lass than 3 seconds
No edema
Extremities warm and dry
Respiratory Status
Respirations quiet and regular
Effort: easy or unlabored
Symmetrical expansion of chest
Denies any S.O.B. or difficulty breathing
Lungs sound clear to ausculation: Anterior
Posterior, and Lateral chest regions
ABNORMAL
Disoriented, forgetful
Responds to pain only
Unresponsive
Speech mumbled, slurred, aphasic
Verbal expression of distress / anger

Affect: sad, anxious, tearful, apathetic, flat affect
Pupils constricted, dilated, or non-reactive

Pupils unequal: L>R or R>L Size:
Hand grasp unequal, weak (R or L stronger)
Sensation reduced or absent: Anesthesia
Paresthesia: Tingling, burning, crawling, itching
Sclera of eyes: Yellow (icterus) or red/pink
Drainage from eyes
Visually impaired: Blind? Which eye?
Artificial eye: ________Rt _______Lt
Drainage from ears: color, amount, odor, Rt or Lt
Bruises/cuts/abrasions on head
Pulses irregular, thready, bounding

Capillary refill greater than 3 seconds
Peripheral pulses decreased, non palpable
Found only by Doppler: Name pulse site
Unequal pulses RUE___LUE___RLE___LLE___
Trace, 1+, 2+, 3+, 4+ pitting/nonpitting edema
Extremities cool / hot / moist
Forehead cool / hot / moist
Respirations shallow or deep
Respirations labored
Asymmetrical chest expansion
Lungs sounds absent or decreased
Adventitious lung sounds: ____fine crackles or
___coarse crackles___ wheezes(inspiratory/expiratory)
Nail beds and mucous membranes pink

No cough noted
No use of excessory muscles
Pulse Oximetry: > or = 95% on room air
Incentive Spirometer: Goal________________
Pt's achievement:__________cc_____#q hour____
Gastrointestinal Status
Bowel sounds auscultated in all 4 quadrants
Passing flatus
Denies nausea
Abdomen soft,non-tender, non-distended
Bowel movements w/in client's normal pattern,
color and consistency: Last BM__________
Continent of stool
Diet Served:___________________________
Intake: % of food eaten on meal tray __________
Tolerance for food: no nausea/emesis
Oral fluid intake:__________________cc
Urinary Status
Urine clear, yellow to amber: By history or by
observation
Voids without difficulty
Continent of urine
No strong/unusual odor to urine
Output: ________________cc
Musculoskeletal Status
Ambulatory and independent
Balanced gait
AROM X 4 extremities: w/in client's norm &
symmetrical strength
Bilateral Homan's Sign: Negative
Able to perform leg exercises: ankle circle, toe
points & quadracept isometric contraction
Plexi-pulse, Pnuematic sequential TEDS or other
anit-thrombotic/embolic devices properly applied
and in use at the bedside
How far did they ambulate?__________________
Skin / Mucous Membrane Status
Color within client's norm
Skin warm, dry, intact, normal turgor
Cough: non-productive (dry or moist) or ineffective

Cough: productive sputum: color, odor, loose liquid
or thick and sticky, amount_________
Cough: persistent or occasional
Nail beds and/or mucous membranes pale, dusky
Complains of difficulty breathing or feeling SOB
Pulse Ox SpO2 drops 5 points or is under
specified parameter. Record your actions
Using accessory muscles of respiration (intercostal
retractions, neck muscles)
Unable to breath with HOB flat (Orthopnea)
Bowel sounds decreased or absent: RUQ,LUQ,RLQ,LLQ
Abdomen distended, firm, tender to touch, obese
Denies passing flatus
Complains of nausea or vomiting
Appetite decreased or absent
Feeding tube type: ____________________
Type solution: ___________ Rate: ________
NG tube: Type_________ Size_________
Gravity or Suction: Low/High, Intermittent/Continuous
Drainage:_______________________________
Diarrhea or Constipation # of stools _________
Incontinent of stool
Ileostomy/Colostomy: Amount____________cc
Color and consistency:____________________
Stoma: Pink?___ Moist?___ Non-retracted?___
Intactness of bag and condition of skin__________
Presence of flatus in colostomy bag? Y or N
Urine cloudy, _________ color
Incontinent, burning, frequency, or urgency
Other observations of urine: mucous, sediment,
presence of blood or blood clots, stones, tissue
Does urine foam when foley bag is shaken
Foley Catheter/Superpubic Catheter Size:_______
Bladder Spasms
CBI (Continuous Bladder Irrigation)
Output _______cc Voided/Foley/Ureterostomy/
or Ileal Conduit
Urine strained for stones___________________
Foley discontinued ________time________cc
DTV: Due to Void Time: ___________
Need for catheterization: Symptoms:___________
Non-ambulatory
Requires assistance:Specify amount/type
Gait unsteady
ROM_____ decreased_____ assymetrical
Contractures
Weakness:
Positive Homan's Sign:
Unable to perform leg exercises: reason:
Refuses to wear/use anti-thrombotic equipment
Color pale, ashen, flushed, jaundiced, red,

mottled, cyanotic _________ body part
Skin cap refill < 3 seconds

Mucous membranes moist and intact
Gums do not easily bleed
Tongue pink, moist, non-coated, non-furrowed
Incision Status
Location: ___________________________
Incision dry, intact, edges approximated with
Staples, sutures, or steri-strips
Free of drainage, erythema, edema, eccchymosis
Open to air or coverd with:___________________
Client instructed not to touch incision wth hands
Presence of protective dressing: Duoderm,
Elastogel, other:
Cool, cold, hot, moist, clammy, diaphoretic,

scaly
Rash: c/o itching / burning, color, raised
_________________ body part
Non-blanchable erythema
Skin tear, bruise, petechia, abrasion, lacerations,
surgical incision, wounds, pressure sore/reddness
Wound: Red, yellow, black
Stage I, II, III, IV decubiti, Measures:________cm
Drainage: color, consistency, amount, odor
Lips, tongue, dry, cracked
Tongue: dry, furrowed, coated______________
Drainage type: clear, serosanguineous,
sanguineous, purulent: Color______ odor_______
Drainage amount: light, moderate, heavy
How many dressings saturated?
Dressing marked: shadowed
Incision nonapporximated: Where?____________
May draw picture to describe
Drains: Jackson-Pratt/Hemovac/other:_________
Time emptied:________ Amount:________cc
Dressing: Location________________________
Changed?_______________________________
Pain
Absence of acute and / or chronic pain
Location: ___________________________
No surgical pain
Rating: 1-10 scale, Keep below 5
No headache
Description:
No backache
Interventions:
No leg pain
Medications PRN:
No pain at tip of IV catheter on gentle palpation
PCA flow sheet completed

Epidural flow sheet completed
PCA Parameters:
Epidural Parameters:
Venous Access
Type: Peripheral, CVC-TL, PICC, Port, Hickman
Infiltration S&S:__________________________
Location(s) and Solution with Rate:
Infection/Phlebitis S&S:_____________________
#1:___________________________
Tenderness or pain at tip of IV catheter
#2:____________________________
Leaking of IV site: dressing wet
#3:____________________________
IV site: clean, dry, intact; no redness, swelling
or pain at insertion site
Date IV needs to be changed: ______________
Date of IV tubing change:____________________
IV changed to INT: Y or N
IV intake ______ pump cleared Y/N Credit____cc
Patient Teaching Done: Demonstrates Understanding

Teaching/Reinforcement of Incentive Spirometry
Coughing, deep-breathing & splinting of incision
SAFETY
Chart where patient is left:______________________
Side rails (# up_____)
Leg exercises: ankle circles, toe points, quad sets
Call light in reach
I&0
Restraints reapplied
Wound Care
HOB _____________
Other:
IV rates correct
Oxygen at proper flow rate____________
Bed in low position
Bed locked
Environment clean/fresh water/Kleenex/phone in reach
Enough gloves/equipment for next nurse
MAR & Nurses' notes in proper place
I&O and VS recordered on PCT sheet
Reported off to nurse
PRN medications given: Be specific on reason/assess

RX and Time:
Misc:
Physician Visits
Labs and Diagnostic tests done:
Family:
Left floor to smoke?
Procedures Done
Isolation Maintained: Type___________________

Special Precautions Maintained such as thrombocytopenic, latex sensitivity, no IV sticks to a
specified extremity etc
Follow-up results of PRN Medications
Equipment/Tubes/Drains: Include descriptions and I&O

IV pump
PCA pump
Kangaroo pump
Ostomy appliances
NG
Gastrostomy
PEG
PEJ
PEG/PEJ
JP (Jackson-Pratt)
Hemovac
Plexipulses
SCDs
TED Hose
Chest Tube to Water-seal drainage:
#_____ Marked at_____ccMajor_____cc increase
#_____ Marked at_____ccMinor_____cc increase
Suction Water-seal: Y or N _________cm
Fluctuation or Tidaling with inspiration: Y or N
Presence of subcutaneous emphysema
Foley
Wound Vacuum:
Other:

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Student Name_____________________

Rock Valley College

MEDICAL - SURGICAL CLIENT ASSESSMENT

Verbal expression of distress / anger

Pupils constricted, dilated, or non-reactive

Pulses irregular, thready, bounding

Nail beds and mucous membranes pink

Cough: non-productive (dry or moist) or ineffective

Color pale, ashen, flushed, jaundiced, red,

Skin cap refill < 3 seconds

Cool, cold, hot, moist, clammy, diaphoretic,

Rating: 1-10 scale, Keep below 5

No pain at tip of IV catheter on gentle palpation

PCA flow sheet completed

Location(s) and Solution with Rate:

Tenderness or pain at tip of IV catheter

Leaking of IV site: dressing wet

Patient Teaching Done: Demonstrates Understanding

Leg exercises: ankle circles, toe points, quad sets

Call light in reach

PRN medications given: Be specific on reason/assess

Isolation Maintained: Type___________________

Equipment/Tubes/Drains: Include descriptions and I&O

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