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    Kent State University College of Nursing N20020 Head To Toe Assessment Documentation Guide General Survey

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    Jamie Sims
    This document provides a guide for conducting and documenting a head-to-toe assessment of a patient. It includes sections to document information about the patient's general survey including vital signs, assessments of the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, back, and skin. Assessment areas are organized from head to toe. Guidelines are also provided for documenting pain levels using a standardized scale and assessing level of consciousness using the Glasgow Coma Scale.

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    Kent State University College of Nursing N20020 Head To Toe Assessment Documentation Guide General Survey

    Uploaded by

    Jamie Sims
    51 views3 pages
    This document provides a guide for conducting and documenting a head-to-toe assessment of a patient. It includes sections to document information about the patient's general survey including vital signs, assessments of the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, back, and skin. Assessment areas are organized from head to toe. Guidelines are also provided for documenting pain levels using a standardized scale and assessing level of consciousness using the Glasgow Coma Scale.

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    Head to Toe Assessment Guide

    Original Title

    Assessment Guide

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    This document provides a guide for conducting and documenting a head-to-toe assessment of a patient. It includes sections to document information about the patient's general survey including vital signs, assessments of the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, back, and skin. Assessment areas are organized from head to toe. Guidelines are also provided for documenting pain levels using a standardized scale and assessing level of consciousness using the Glasgow Coma Scale.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    51 views3 pages

    Kent State University College of Nursing N20020 Head To Toe Assessment Documentation Guide General Survey

    Uploaded by

    Jamie Sims
    This document provides a guide for conducting and documenting a head-to-toe assessment of a patient. It includes sections to document information about the patient's general survey including vital signs, assessments of the head, eyes, ears, nose, mouth, neck, chest, abdomen, extremities, back, and skin. Assessment areas are organized from head to toe. Guidelines are also provided for documenting pain levels using a standardized scale and assessing level of consciousness using the Glasgow Coma Scale.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 3

    Kent State University

    College of Nursing
    N20020
    Head to Toe Assessment Documentation Guide
    General Survey
    Patient Name Age Height Weight Nurses Name/Date
    Temperature Radial Pulse Respirations Blood Pressure Pain O2Sat/O2
    Head/Sin
    Skin olor/!uosa/Sars "aial e#pression "aial/Smile s$mmetr$ Tongue/!uous
    !em%ranes
    Throat/Tonsils
    &lasses/'ontats
    Hearing Aids
    Teeth/Dentures Nasal/(ar Drainage Braden Sore
    !!!!/2"
    Skin Turgor
    'ondition o) Hair/Nails *O' Alertness +A,O- 'larit$ o)
    Speeh
    Pupils/*ight/Aommodation
    +P(RR*A-
    &lasgo. 'oma Sale
    !!!!/#$
    Appetite/Diet +assess diet o/er last 20 hours-
    Nec
    Range o) !otion
    +RO!-
    Trahea !idline1 2ugular 3ein Distention
    +23D-1
    'arotid Pulse1
    C%est
    Respirator$ rh$thm/e))ort
    SOB/DO(
    Bilateral lung sounds 'ough &'ygen
    N/A
    Anterior Posterior Non4produti/e Produti/e Trac%
    N/A
    'harater o)
    Sputum
    C%est tu(e
    N/A
    Apial rate/rh$thm Pulse de)iit 'hest shape/s$mmetr$
    Head)to)Toe Assessment Documentation Guide)continued 2
    A(domen
    Si5e/Shape/Tenderness Bo.el Sounds *B!
    Amount/shape/olor
    'onstipation/Diarrhea
    Nasogastric/*+G tu(e
    N/A
    A(domina
    l (ruits
    N/A
    &stomy
    N/A
    Drains
    N/A
    Nausea/3omiting Tu(e feeding
    N/A
    6rinar$ Pattern/ "re7uen$/Pain Color/&dor/Sediment,
    N/A
    -oley
    N/A
    +'tremities
    !o/ement +!A(- Ati/it$/assistane1 'olor/temperature (dema4loation Pedal pulses
    Hand grasps1 Pitting Non4
    pitting
    Dorsalis
    pedis
    Posterior
    ti%ial
    *eg strength1 'apillar$ re)ill
    .ntravenous t%era/y
    N/A
    A0 S%unt)T%rill/1ruit
    N/A
    1ac
    Skin ondition1
    Sacrum/coccy'/sca/ula ) N/A
    *ain
    *e/el/loation/radiation/paresthesia/relie) measures
    Nursing Diagnoses
    #2
    22
    "2
    Table 25-4 GLASGOW COMA SCALE
    Best Eye-Opening Response Best Verbal Response
    Best Motor
    Response
    Purposeful and
    spontaneous
    4 Oriented 5 Obeys commands 6
    To voice 3 Disoriented 4 Localizes pain 5
    To pain 2 Inappropriate ords 3 !it"dras to pain 4
    #o response $ Incompre"ensible sounds 2 %le&ion to pain 3
    'ntestable ' #o response $ (&tension to pain 2
    'ntestable ' #o response $
    'ntestable '

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