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Head-to-Toe Narrative Assessment Example

Note: this sample charting was from a patient with a recent CVA. The areas of assessment you need to focus on depend on what is wrong with your particular patient.

10/4/96 2100. 86 y.o. male admitted 10/3/96 for L CVA. V/S 99.2 T, 100, 20, 140/76. Vital signs assessed q 2 hrs, Nursing Assessments every 4 hours, Neuro Checks q 4 hrs. Alert and oriented x 3. Responds appropriately to verbal stimuli. PERL, 2-3 mm bilateral. No slurring of speech. At risk for injury related to dysphagia, on soft-thick dysphagia diet, feeds self with assistance. No JVD. Grips unequal, strong on right, weak on left. Left arm has limited mobility due to weakness secondary to CVA. At risk for injury (falls) related to limited mobility, side rails up x 4, call light in reach, patient needs assessed q 2 hours. Has a saline lock R forearm, flush q 8 hours, patent and intact, site free from redness or drainage. (If your patient has an infusing IV, make sure you record the fluid and rate in your assessment). Lung sounds clear in all lung fields. (If your patient is on O2, make sure you record the O2 rate and delivery system here, along with pulse ox readings). Heart sounds clear and regular, patient has a history of heart disease and has an implanted pacemaker (If your patient is on a heart monitor, record the rhythm here - such as normal sinus rhythm, A-fib ect.). Bowel sounds active in all 4 quads, abd non-tender to palpation. (If your patient has an abdominal incision, record the condition of it here). Last BM 17:15 today, brown, soft formed. Has a history of constipation. Urine clear yellow. Uses urinal, has occasional episodes of incontinence. Peri-area skin currently clear and intact, with no areas of redness. At risk for skin breakdown related to limited mobility and incontinence, at risk for pneumostatic pneumonia due to limited mobility, TCDB q 2 hr, up in chair TID with assist of 2 people. Limited mobility L leg, weakness due to CVA. At risk of DVT due to immobility, TEDS on bilateral, Active ROM Right leg, Passive ROM left leg, q 4 hours. Calf pumps x 5 bilateral encouraged every 2 hours while awake. Homans sign negative bilateral. Pedal pulses palpable bilateral. Feet cool, dry, intact, with thick toenails bilateral. Capillary refill toes < 2 Sec. Shift Intake 850, Output 750 cc Fluid balance Positive 100 cc for this shift. ----------------------------------------------------------------------------------------M. Bennett RN, ISU.

Originally posted at: http://www-isu.indstate.edu/mary/chart.htm


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