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Healt h Assessment
Health Assessment-Bried head to toe
| Question | Answer |
|---|---|
| What to ask: | how was your night? how did you sleep? any pain now? 0-10? do you need to use restroom before morning assessment? address pain and bathroom before continuing |
| 1. | any distress? what's their color? are they on O2? tube feedings? how high is the HOB supposed to be? |
| 2. | what does their IV look like? red, infiltrated pain? |
| 3. | EOMS, pupillary response, smile |
| 4. | can you grip my fingers? note strength- 5/5 normal. assess radial pulses. Can you push down on my hands c feet? not strength. check pedal and post tib pulses. 2/3 norm. |
| 5. | listen to lung sounds. are they clear? what would crackles sound like? rhonchi? wheeze? |
| 6. | listen to cardiac sounds, 5 spots. what would a murmur sound like? how would you grade it? |
| 7. | if you hear murmur, assess for bruit in neck. |
| 8. | listen to bowels. present? any pain? any incisions? drains or tubes? |
| 9. | check legs. TEDS? or SCDs that are supposed to be on? |
| 10. | check back, any skin breakdown? listen to posterior lung sounds now. Are they clear? rub back with powder/lotion and reposition in bed. |
| 11. | ask them if there is anything you can get them. |
Created by:
rlvander
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