Writing a head to toe assessment charting

Narrative notes can be tricky for nursing students…what do you write, what if you miss something, what if you muck it all up and look like a goofball?

This is an example of a head-to-toe narrative assessment note. I have my first-semester nursing students start by writing out a narrative assessment on the clinical floor, before proceeding to any facility assessment flowcharts.

Responds appropriately to verbal stimuli; no slurring of speech. At risk for aspiration related to dysphagia; on thickened dysphagia diet. Feeds self with assistance. Skin acyanotic with loose turgor. Mucous membranes moist and pink. Apical pulse regular rate and rhythm; s1, s2 noted.

Pink nailbeds with capillary refill less than 2 seconds in all extremities. Peripheral pulses palpable in all extremities.

Right arm has limited mobility due to weakness secondary to cva. Has a 20 gauge saline lock to left lateral forearm. Site is free from redness or drainage, with tegaderm dressing intact.

If your patient has an infusing iv, make sure you record the fluid and rate in your assessment.

Complete Head-to-Toe Physical Assessment Cheat Sheet • Nurseslabs

Uses urinal, has occasional episodes of incontinence. No skin breakdown noted. Instructed to call for any needs or to request assistance before attempting to get up. Will continue to monitor closely.Jun 30, '07 by VickyRN Here is a head-to-toe narrative charting template that I developed for my first semester RN students last.

semester: 2/12/ 86 y.o. male admitted 2/1/07 for left CVA. VS C, HR 97, RR 22, BP / Alert and oriented x 4; denies any pain or distress. PERRLA.5/5(1). A head-to-toe nursing assessment is a comprehensive process that reviews the health of all major body systems (from “head-to-toe,” hence the name).

head-to-toe assessments are usually performed by nurses as part of a physical exam, although physician assistants, EMTs, and doctors also sometimes perform head-to-toe assessments.

Nursing assessment is an important step of the whole nursing process. Assessment can be called the “base or foundation” of the nursing process.

With a weak or incorrect assessment, nurses can create an incorrect nursing diagnosis and plans therefore creating wrong interventions and evaluation.

Head-to-Toe Assessment: Complete Step Checklist | LoyalMD

Head-to-Toe Narrative Assessment Example Note: this sample charting was from a patient with a recent CVA (Cerebral Vascular Accident or Stroke, a clot or bleed in the brain’s vascular system.) The areas of assessment you need to focus on depend on what is wrong with your particular patient.

Establishing a good assessment would later-on provide a more accurate diagnosis, planning and better interventions and evaluation, that’s why its important to have good and strong assessment is. Below is your ultimate guide in performing a head-to-toe physical assessment.

Oct 24,  · Skin of abdomen is free of striae, scars, lesions, or rashes. Umbilicus is midline and recessed with no bulging. Abdomen is flat and symmetric with no bulges or lumps. No bulges noted when patient raises head. No peristaltic movements seen.

Soft .