Mensy Germain

May 12th, 2010 Nursing Notes

Head to Toe Assessment

Initial Observation
Skin color : normal, no sign of lesion, bruise, ease of respiration Patient's level of consciousness, speech, orientation

Head
Patient very responsive to questions No presence of confusion Alert and oriented Pupils are equal and reactive to light Neck for neck vein distention : No sign

Vital Signs:
Temperature : 98.9 F Resp 20, clear unlabored, respiration 20 BP 128/78

Pain
No sign of pain Pt not in medication

Chest : General heart and Lung Assessment

Apical pulse strong , regular 64 Heart rate normal Chest wall equally moved

Abdomen
Observe the abdomen for symmetry, contour, movement Listen in each of the four quadrants for bowel tones. Lightly palpate if indicated (tenderness, bladder distention) No presence of Bowel sounds Abdomen soft and tender Time of last bowel sounds : 1800pm Void clear, yellow urine, without difficulty or discomfort

Extremities No skin lesions or pressure area No presence of edema Moves with equal and normal strengh Pedal pulse palpable, capillary refill < 3sec
posterior tibial and dorsalis pedis pulses Motion/Sensation: Push/pull, Leg raise Radial Pulse Strong 64, hand grasp strong