NurseInTheMaking LLC are simply guides and should not be used over and above your course material and teacher instruction in nursing school.

By purchasing this material, you agree to the following terms and conditions: you agree that this ebook and all other media produced by NurseInTheMaking LLC are simply guides and should not be used over and above your course material and teacher instruction in nursing school.When details contained within these guides and other media differ, you will defer to your nursing school’s faculty/staff instruction. Hospitals and universities may differ on lab values; you will defer to your hospital or nursing school’s faculty/staff instruction. These guides and other media created by NurseInTheMaking LLC are not intended to be used as medical advice or clinical practice; they are for educational use only. You also agree to not distribute or share these materials under any circumstances; they are for personal use only.© 2021 NurseInTheMaking LLC. All content is property of NurseInTheMaking LLC and www.anurseinthemaking.com. Replication and distribution of this material is prohibited by law. All digital products (PDF �les, ebooks, resources, and all online content) are subject to copyright protection. Each product sold is licensed to an individual user and customers are not allowed to distribute, copy, share, or transfer the products to any other individual or entity, they are for personal use only. Fines of up to $10,000 may apply and individuals will be reported to the BRN and their school of nursing.www.etsy.com/shop/nurseinthemaking @Kristine_nurseinthemaking @anurseinthemaking [email protected] @nurseinthemakingkristine @NurseInTheMaking

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© 2021 NurseInTheMaking LLC patient background room #age admitting diagnosis/medical history name sex code allergies male female full DNR limited nka precaution droplet contact airborne noteslabsPT INR PTT Na K Glucose HCO

• Cr Cl BUN Hgb WBC HCT PLT TP Ca ALB PO

2 BILI ALT ALP AST LDH

Assessment Neuro Cardiac

GI / GU

Integumentary Vitals Respiratory Musculoskeletal Iv / fluids / drips/ blood bp hr pulse rr t 02

© 2021 NurseInTheMaking LLC Head to toe assessment Template inspect1palpate2percuss3auscultate4 hair clean infestation diRty hair loss sparse baldness nose Skin intact symmetrical sneezing Congestion runny nose orientation awake drowsy alert sedated restless confused vital signs

Blood pressure:

Heart rate:

Respiratory rate:

Temperature:

oxygen saturation:

eyes moist pink conjuntiva yes no drainage or discharge?white scerla yellow/jaundice

REMEMBER:REMEMBER:

PERRLA

Pupils Equal, Round, Reactive to Light, & Accommodation Level of Consciousness person place time situation A&O x skin turgor elastic tented color pink pale flushed moisture clamy dry diaphoretic temperature hot warm cold PAIN

INTENSITY:

0 1 2 3 4 5 6 7 8 9 10

LOCATION:

description:

no pain worstworst painpain Mouth

Mucosa:

pinkmoistdrysore/lesions

© 2021 NurseInTheMaking LLC Head to toe assessment Template neck symmetrical use of accessory muscles jugular vein distention lower extremities grip strength range of motion dorsalis pedis pulse * posterior tibial pulse * capillary refill edema pitting non-pitting chest

1+ 2+ 3+ 4+ normal full bounding, strong pulse is absent diminished * pulse chart regular irregular rhythm breath sounds clear wheezing crackles diminished

other:

Auscultate lung sounds posteriorly & laterally regular irregular rhythm heart sounds muffled gallopnormalbruitsmurmurswhooshing

other:

Auscultate heart sounds (A, P, E, T, M) with diaphragm and bell Aortic Right 2nd intercostal space Pulmonic Left 2nd intercostal space ERB’s Point (S1, S2) Left 3rd intercostal space Tricuspid Lower left sternal border 4th intercostal Mitral Left 5th intercostal, medial to midclavicular line abdomen symmetrical rounded scars distended ascites inspection inspect1auscultate2percuss3palpate4

Assess in different order:

bowel sounds Rlq absent hypoactive normoactivehyperactive ruq absent hypoactive normoactivehyperactive luq absent hypoactive normoactivehyperactive llq absent hypoactive normoactivehyperactive upper extremities grip strength capillary refill range of motion radial pulse * capillary refill time (CRT) normal <2-3 seconds

location:

0+1+2+3+4

ears symmetrical hearing devices earwax discharge