Monday, September 27, 2010

I'm a student nurse & inevitability oblige next to documentation of a come first to toe assessment. Can anyone relief me ?

Here's an example of a healthy person's assessment. My rule of thumb is start at the skipper and cover each system.
Pt. appears stated age, well-groomed, no body odor. Alert and orientedx3. Conversation clear and appropriate. No headache. Eyes clear, no rosiness, swelling or discharge. External ocular muscles intact. No double mirage or blurred vision noted. Gross auditory function intact; pt. responds appropriately to question. Mucous membranes moist. S1 and S2 auscultated, no S3 or S4 noted. No murmur. Pulse 72, regular at left radial. Peripheral pulses present, equal bilaterally and strong. BP 116/72. Skin pink, heat up and dry. Resps. easy, straightforward, quiet. No discharge from snout, no cough. Lungs auscultated, clear to bases. Bowel sounds auscultated to adjectives 4 quadrants. Last BM this AM, soft, brown, formed. No nausea or vomiting. No pain on palpation of belly. No pain, urgency, or frequency of voiding noted. Urine is clear, sickly, no foul odor. Functional range of motion, no swelling or reddishness of joints. Pt. is pleasant, no voiced concerns.
This is more thorough than you usually see contained by practice, and there are abbreviation to make it shorter, but it's pious practice to know what all go into an assessment. Just write what you saw, heard, feel, smelled, and also what you didn't see. That way, it's specified that something wasn't there, not basically that you didn't look for it. Good luck, we nurses have to stick together!
Sure, Head is on top and foot are on the bottom. The middle is your boobies.

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