Head-to-Toe Narrative Assessment Example



Head-to-Toe Narrative Assessment Example

Note: this sample charting was from a patient with a recent CVA. The areas of assessment you need to focus on depend on what is wrong with your particular patient. | |

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|10/4/96 2100. 86 y.o. male admitted 10/3/96 for L CVA. V/S 99.2 T, 100, 20, 140/76. Vital signs assessed q 2 hrs, Nursing |

|Assessments every 4 hours, Neuro Checks q 4 hrs. Alert and oriented x 3. Responds appropriately to verbal stimuli. PERL, 2-3 mm |

|bilateral. No slurring of speech. At risk for injury related to dysphagia, on soft-thick dysphagia diet, feeds self with |

|assistance. No JVD. Grips unequal, strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. |

|At risk for injury (falls) related to limited mobility, side rails up x 4, call light in reach, patient needs assessed q 2 hours. |

|Has a saline lock R forearm, flush q 8 hours, patent and intact, site free from redness or drainage. (If your patient has an |

|infusing IV, make sure you record the fluid and rate in your assessment). Lung sounds clear in all lung fields. (If your patient |

|is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Heart sounds clear and |

|regular, patient has a history of heart disease and has an implanted pacemaker (If your patient is on a heart monitor, record the |

|rhythm here - such as normal sinus rhythm, A-fib ect.). Bowel sounds active in all 4 quads, abd non-tender to palpation. (If your |

|patient has an abdominal incision, record the condition of it here). Last BM 17:15 today, brown, soft formed. Has a history of |

|constipation. Urine clear yellow. Uses urinal, has occasional episodes of incontinence. Peri-area skin currently clear and intact,|

|with no areas of redness. At risk for skin breakdown related to limited mobility and incontinence, at risk for pneumostatic |

|pneumonia due to limited mobility, TCDB q 2 hr, up in chair TID with assist of 2 people. Limited mobility L leg, weakness due to |

|CVA. At risk of DVT due to immobility, TEDS on bilateral, Active ROM Right leg, Passive ROM left leg, q 4 hours. Calf pumps x 5 |

|bilateral encouraged every 2 hours while awake. Homans sign negative bilateral. Pedal pulses palpable bilateral. Feet cool, dry, |

|intact, with thick toenails bilateral. Capillary refill toes < 2 Sec. Shift Intake 850, Output 750 cc Fluid balance Positive 100 |

|cc for this shift. ----------------------------------------------------------------------------------------M. Bennett RN, ISU. |

|Originally posted at: |

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