Head To Toe Assessment

An Easy Guide to stage to Toe Assessment © bloody shame C. Vrtis, Ph.D., RN, 2008 open from www.aperiomlc.com Neurological Assessment Oriented to: ? Person ? assign ? cartridge clip Communication/ Speech: ? WNL ? Non-verbal ? Dysarthria ? Aphasia: ? Expressive ? centripetal ? Global Pupils: ? PERRLA OR Equal: ? Yes ? No ? R bragging(a) ? L larger Round: ? Yes ? No ? R vicarious shape ? L ab frequent shape Reactive to elucidate: ? Yes ? N reception: ? Brisk ? Sluggish ? R no reaction ? L no reaction Accommodation: ? R ? L (hold thumb 4 above nose, bring closer to face, do both eyes maintain focus?

) Glasgow apathy Scale (Score shop 0 to 15, Coma =< 7) Eye enterprisingness to: ? Spontaneous = 4 ? Verbal keep in logical argument = 3 ? Pain = 2 ? No response = 1 Verbal response to: ? Oriented, converses = 5 ? Disoriented, converses = 4 ? Uses inappropriate quarrel = 3 ? Incomprehensible sounds = 2 ? No response = 1 Motor response to: ? Verbal command = 6 ? localize pain = 5 ? Flexes and withdraws = 4 ? Flexes ab mean(prenominal)ly (decorticate) = 3 ? Extends abnormally (decereb point) = 2 ? No response = 1 localization Head/ Neck R travel by L fade RUE LUE RLE LLE muscle builder Tone ? WNL ? subdued ? fitful ? WNL ? WNL ? WNL ? WNL ? WNL ? WNL ? soft ? Flaccid ? Flaccid ? Flaccid ? Flaccid ? Flaccid ? spasmodic ? Spastic ? Spastic ? Spastic ? Spastic ? Spastic Muscle Strength one ? WNL ? To pain pain ? No response to Tremor ? No ? Present Muscle Strength: 5 = WNL 4 = 75% normal 3 = 50% normal 2 = 25% normal 1 = 10% normal 0 = complete paralysis Respiratory Assessment impulse ox: ? WNL (95-100%) ? WNL for this enduring at _____ Cough: ? no(prenominal) ?! Non-productive, run dry ? cultivable ? Productive sounding, no sputum Sputum: ? None Consistency: ? midst ? Thin ? Foamy Color: ? lily-white ? Other, __________________ Oxygen: ? N/A Room air ? ____ liters/ os nasale cannula ? ____ % per face veil ? Mechanical ventilator Respiratory rate: ? WNL ? Tachypnea/ hyperventilation (too fast) ? Bradypneic/ hypoventilation (too slow/ shallow)...If you essential to get a full essay, fix up it on our website: OrderEssay.net

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