Head-to-toe Assessment Date:

Assessment conducted by: MonicaL. Borja Time:

LOC
Drow Letha
Alert Straporous
sy rgic
Orientation
Person
Place
Time
Situation
Vitals
Temp 36.8 R: 102 cpm
BP 124/84 mmHg PulseOx: 92%
Head
Hair
PERLA
Nose
Ears
Mouth
Midline tongue
Moist
Lesions
Dentitions
Neck
Carotid Pulse JVD+ Trachea midline
Chest
ApicalPulse Muffled Arrythmia
Breath Sounds Anterior Posterior Lateral
Chest Symmetry
Skin Turgor(clavicle)
Abdomen
Inspection: globular
□Auscultation
□ LUQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ RUQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ LLQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□ RLQ (active / hyper / absent) Active ✘ Hyper ✘ Absent
□Palpation: soft, non-tender

Upper Extremities
□Radial Pulse
◦ other:
□ Temp vsTrunk (warm / cool)
□Grip equal and strong_______________
□Capillary refill <2 sec
□ Vein Filling________________________

Lower Extremities
□Hair present
□Edema
□Foot strength
□Homan's sign (+ / - ) (-) (+)
□Temp vs Trunk ( warm / cool ) warm cool
□Nails Yellowed Thickened Ingrown
□Pedal pulse
ROM Strength
□ Upper R □ Upper R
□ Upper L □ Upper L
□ Lower R □ Lower R
□ Lower L □ Lower L
□ Sensation

General Assessment
□ Weight: 156 lbs Height: 4'11 (149.86 cm)
□ BM:

Pain Assessment
□ Acute/Chronic □ Intensity ( 0-10)
□ Location
□ Duration
□ Characteristic
□ Precipitation
□ Frequency
□ Non-Verbals
□ Relief Factors
□ Sleep

Skin Assessment
□ Description _______________________
traporous Coma
 REGISTRATION SHEET

Patient's Name: Dusug, Ika Monalisa

Birthday: March 15, 1984
Hospital Registration #:
Religion: Roman
Address: 154 Catholic Diliman, Lungsod Quezon, Kalakhang
Maginhawa,
Maynila
Date of Admission:
Chief Complaint:
Admitting Diagnosis:

Other Diagnoses:

Allergies: (Food, Meds, Scents, Particles, Others)

Reaction to Allergies:

Contact in Case of Emergency :

Name: Leonardo da Vinci
Address:
CellPhone # / Landline #:
Nursing Care Plan
Date Started (MM,DD,YYYY) Target Date (MM,DD,YYYY)
Cues Nursing Diagnosis Nursing Objectives Nursing Interventions
Evaluations
 VITAL SHEET
Date: Date: 01/31/2020 Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
SHIFT: AM PM NIGHT PRN AM PM NIGHT PRN AM
TIME 920
TAKEN:
BP 124/83

TEMP
(Degrees 36.8
Celsius)

TEMP
ROUTE
(Oral, AX
Axillary,
PR,
Forehead
Scan)
PR 102
RR 23
O2 SAT 98%
Pain 0/10
Scale:
HEET
Date: (MM/ DD/ YY) Date: (MM/ DD/ YY)
PM NIGHT PRN AM PM NIGHT PRN