Remerciez-le!

Remerciez @Admin pour avoir partagé cet document gratuitement, de la manière la plus simple, en partageant sur les réseaux sociaux.

Kent state university college of nursing n20020 head to toe assessment documentation guide general survey

General Survey Patient Name Kent State University College of Nursing N Head to Toe Assessment Documentation Guide Age Height Weight Nurse ? s Name Date Temperature Radial Pulse Respirations Blood Pressure Pain O Sat O Head Skin Skin color Mucosa Scars Facial expression Facial Smile symmetry Tongue Mucous Membranes Throat Tonsils Glasses Contacts Hearing Aids Teeth Dentures Nasal Ear Drainage Condition of Hair Nails LOC Alertness A O Braden Score Skin Turgor Clarity of Speech Pupils Light Accommodation PERRLA Glasgow Coma Scale Appetite Diet assess diet over last hours Neck Range of Motion ROM Trachea Midline Jugular Vein Distention JVD Carotid Pulse Chest Respiratory rhythm e ?ort SOB DOE Bilateral lung sounds Cough Anterior Posterior Non-productive Productive Character of Sputum Oxygen N A Trach N A Chest tube N A Apical rate rhythm Pulse de ?cit Chest shape symmetry CHead-to-Toe Assessment Documentation Guide-continued Abdomen Size Shape Tenderness Bowel Sounds LBM Ostomy N A Drains N A Nausea Vomiting Amount shape color Constipation Diarrhea Urinary Pattern Frequency Pain Color Odor Sediment N A Nasogastric PEG tube N A Tube feeding N A Abdomina l bruits N A Foley N A Extremities Movement MAE Hand grasps Leg strength Activity assistance Color temperature Capillary re ?ll Edema-location Pitting Nonpitting Pedal pulses Dorsalis Posterior pedis tibial Intravenous therapy N A AV Shunt-Thrill Bruit N A Back Skin condition Sacrum coccyx scapula - N A Pain Level location radiation paresthesia relief measures Nursing Diagnoses CTable - GLASGOW COMA SCALE Best Eye-Opening Response Best Verbal Response Best Motor Response Purposeful and spontaneous Oriented Obeys commands To voice Disoriented Localizes pain To pain Inappropriate words Withdraws to pain No response Incomprehensible sounds Flexion to pain Untestable U No response Extension to pain Untestable U No response Untestable U C