Focused Head-to-Toe Physical Assessment | Nursing Immersion Checkoff скачать в хорошем качестве

Focused Head-to-Toe Physical Assessment | Nursing Immersion Checkoff

This is the focused head-to-toe physical assessment checklist used during my nursing immersion clinical. The assessment is typically performed in about 10 minutes and includes neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, and safety evaluations. #nursing #nursingstudent #nursingschool #assessment #assessmentforlearning #skills #skillsdevelopment #education #educational #educationalvideo Focused Physical Assessment Checklist (Nursing Immersion) Introduction: Introduce yourself / Identify patient Utilize appropriate PPE Neurological Assessment: Appearance / Behavior Level of Consciousness Orientation (Person, Place, Time, Situation) Speech Responds appropriately / Cooperative Psychosocial concerns Vital Signs (Verbalize abnormal findings): Temperature Pulse Respirations O2 Saturation Blood Pressure HEENT (Head, Eyes, Ears, Nose, Throat): Inspect overall symmetry PERRLA & pupil size Mucous membranes Pain Assessment: (OPQRST framework) ~ OLD CART Onset / Duration Location Description Aggravating / Alleviating factors Related symptoms Severity / Pain scale Integumentary (Skin): Describe assessment findings if present Color / Temperature Moisture Skin turgor Incisions Wounds Cardiovascular Assessment: Auscultate 5 cardiac areas (APETM) Aortic Pulmonic Erb’s Point Tricuspid Mitral (Apical) S1 & S2 heart sounds Rate and rhythm Peripheral Vascular: Peripheral pulses Capillary refill Edema Neurovascular Assessment: (Especially important for orthopedic patients) Pallor Paresthesia Paralysis Respiratory Assessment: Auscultate anterior and posterior lung fields Respiratory rate/rhythm Lung sounds Work of breathing Cough/sputum Oxygen administration Gastrointestinal Assessment: Bowel sounds Palpation and describe findings Appetite/diet tolerance Last bowel movement Genitourinary: Urinary output Amount Color Clarity Musculoskeletal: Symmetry Gait (if appropriate) Range of motion (active or passive) in all extremities Strength Joint swelling or abnormalities Lines / Drains / Tubes: Assess insertion site and device: Color / Temperature Edema Tenderness Drainage Intact / Patent Safety Check: Bed position Side rails Call light within reach