CLINICAL ASSIGNMENT: HEAD TO TOE ASSESSMENT FOCUSED ASSESSMENTS

Date: Student: Airway: Notes:

Pt’s Ini als: Room #: Breathing:
Circula on:
Age: Admission
LOC:
date: Code Orienta on X3:
Safety checks:
status:

Safety and isola on precau ons: **VITALS:

Time: BP: HR: (Reg/Irreg) Site:
Resps /min Sats %: 02 Temp:
Diagnosis and/or Surgery:
**PAIN: L: O: T:
A: R: P:
Analgesia: NVS: GCS: /15 best> eye opening verbal motor
Pupils: L_ R Reac on: L_ R
Previous History: General Appearance: Head/Neck: Motor Strength: hands/arms: feet/legs:
Tubes, Drains, Drsgs, IV’s: Eyes” Mouth/ Sensa on(numb/ ng): hands/arms: feet/legs:
tongue/teeth:Facial Arm dri :
symmetry:
Resp: Ausculta on:
Diet: Respiratory/Chest: Regularity:
WOB/SOB: WOB: Anterior = Right side:
Ac vity:
Chest expansion: Anterior = Le s ide:
ng: Ausculta on: SOB: Posterior = Right side:
use prompts to the right Posterior = Le side: __________________
LAB VALUES:

RESULTS: NORMAL: RESULTS: NORMAL: GI/GU: GI/GU Notes:

Abdo/skin: Abd (shape, distension, tenderness):
Hgb: Mg: BS RLQ: Abd movement/pulsa ons:
Bladder/bowel disten on: BS X4 Quads:
RBC: Ca: Tenderness/masses:
Pain:
Toile ng/ Con nence:
WBC: BUN: Urine output:
Urine/color/clarify/amount: Foley:
LBM:
Platelets: Crea nine: Perineum:

PTT: Glucose: Extremi es: CV/PV/Lympha c:

Arms R/L (pain/deformity/edema/pressure areas/bruises): Chest pain: Onset:
INR: Urinalysis:
Apex (1min):
Legs R/L (pain/deformity/edema/pressure areas/bruises):
Na+: Chest(deformi es/scars):
Peripheral pulses (radial/pedal): CWMS: Hands: Feet:
K+: CWMS: Cap re ll: Cap. Re ll: Hands: Feet:
Handgrip: Flexion (dorsi/plantar): Edema: Calf size/pain:
Skin integrity/pressure areas: Pulses: Radial: Brachial: DP: PT:
MEDICATIONS:
Back/coccyx:

ADLs: Musc. Notes:

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 Falls risk: Weight bearing: Muscle strength/ROM x4 limbs:
Tests/procedures:
Gait/balance: Assis ve devices: Bony prominences/joints:

Feeding/swallowing: Sleep: Mobility: Skin Integrity (all bony areas):

NOTES AND PLAN INTERRELATED CONCEPT MAP (FROM GIDDENS, 2017)

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Revised Apr 19 HB/LS